Confidential Patient History Form
Name  Date 
Address   City  State  Zip 
Date of Birth   Age   Sex: F/M     Email (please supply) 
Phone (Home)   Cell   Work 
How were you referred to us? Web? Y/N     Personal Referral (Name) 
Have you ever had a colonic before? Y/N   If so, when? (Date)  
Number of bowel movements per day?   or per week?  
Do you use Laxatives? Y/N   What type? 
Have you had any abdominal surgeries?  Y/N     If yes, date(s):  
If yes, please explain:
List any medication you are taking: 
Check off the following items and FREQUENCY (day/week) that you use them with AMOUNTS where indicated:

Artificial Sweeteners  Y/N    Stevia   Y/N
Coffee regular or decaf cups per day /week:
Soda/Carbonated Beverages cups per day /week:
Glasses/Ounces of Water per day /week:   (keep in mind that a measuring cup is 8 ounces)
Fruits / Vegetables / Salads # times per week:
Servings of Bread, Pasta, Rolls, or Crackers per day /week:
Chicken, Fish, Turkey, or Red Meat per day /week:
Dairy (Milk, Cheese or Cottage Cheese) per day /week:     Yogurt per day /week:
Refined Sugars (Cake, Cookies, Ice Cream, Donuts) per day /week:
Chocolate per day /week:

MAJOR HEALTH CONCERNS OR GOALS FOR YOUR HEALTH (Why are you coming to see us?):

COLON HYDROTHERAPY rejuvenates every cell of the body. Colonics release toxins, cleanse the blood, improve digestion, empower the immune system and restore the pH balance of the body. This process will help you feel alive with new life force.

I, , have chosen to have therapeutic treatments at this address.
I understand that no specific therapeutic claim is implied or made by us in administering these sessions.

WE HAVE A 24-HOUR CANCELLATION POLICY AND WE CHARGE FULL PRICE FOR LESS THAN A 2-HOUR NOTICE, UNLESS WE ARE ABLE TO FILL YOUR TIME SLOT. IT WORKS THE SAME FOR BOTH OF US. WE HAVE SET THIS TIME ASIDE FOR YOU AND MAKE SURE THAT WE ARE HERE FOR YOUR SCHEDULED APPOINTMENT.

SIGNED: ________________________________________________________________ Date: __________________

Ventura Center for Healing
19525 Ventura Blvd., Tarzana, CA  91356
Phone (818) 343-3571
www.venturacenter4healing.com

 

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