Please PRINT
legibly on all 3 pages Today’s Date:_________________________
Last
Name: ______________________________
Address:
______________________________
City
______________________________
Day
Phone:___________________Cell #___________________Evening Phone:__________________
E-mail
Address: ______________________________
Age
____Birthday_______________ Sex: M
F Marital
Status: S
M D W
# of Children______
Name of Emergency Contact:
_____________________________
Emergency Contact Phone Number(s):
Daytime:______________________
Yes, your credit card # on file is a requirement .
This will allow you to call
in to book future appointments. Your card will be used ONLY in
the case of a “no show”. If you need to cancel appointments
please call by the day previous to your appointment in order to avoid
the $25.00 “no show” fee. The $25.00 fee will only be charged
if you do not call to cancel an appointment that you do not show up
for. We ask for at least a 12 hour advance cancellation.
Visa/MC ______________________________
Name on Card__________________________
How did you
hear about Soothing Solutions? (Check One)
Yellow Pages Magazine Newspaper Health Expo Television Radio
Internet
Friend ______________________________
Which service are you here for today? (Check all applicable services.)
Colon Hydrotherapy Float Tank Infrared Sauna ISqueeze Foot Massage
Ion Detox Footbath Detox Plan B.E.S.T. Release Therapy Chi Machine Other
Do you plan on trying any other services? Y N Which ones?_____________________
Do you now, or have you ever had any of the following? (Check all applicable)
If you have any of the you should check with your doctor before doing colonic.
Severe Cardiac Disease Abdominal Hernia
Congestive Heart Failure Carcinoma of the Colon
Organic Valve Disease Cirrhosis of the liver
Aneurysm Severe Hemorrhoids (bleeding, open & infected)
Severe Anemia Ulcerative Colitis
Colon Surgery (within 6 mo.) Renal Insufficiency (Kidney)
Diverticulitis Crohn’s disease
Fissures and/or fistulas Pace Maker
Abdominal Surgery (within 6 mo.)
Is it possible that you may be pregnant? Y N
Are your periods regular? Y N Do you suffer from PMS? Y N
Are you currently under
a Doctor’s care? Y N
If yes, please explain: ______________________________
Do you now have any of the following? (circle all that apply)
Headaches Fainting spells Insomnia
History of seizures Loss of weight Fatigue
Dizziness Severe Depression Claustrophobia
Double/blurred vision Severe Mood Swings Fear of the dark
Please list year and type of
any MAJOR illnesses and operations ______________________________
______________________________
Please list known allergies
______________________________
Are you vegetarian? Y N
Do you eat red meat? Y N Do you eat chicken? Y N Do you eat/drink dairy products? Y N
Major physical complaints?
______________________________
______________________________
Any abdominal surgeries? Y N What kind, and how long ago? ___________________________
______________________________
Have you ever had x-rays of
your colon? _______ Why________________Results____
Have you ever had a colonoscopy?
Y N If yes, when?________________Results:_
Have you taken antibiotics for an infection in the past year? Y N
Do you have hemorrhoids?
If
so, are they a bother to you now?
Do you have a history of Colon Cancer in your family? Y N
Have you ever had a colon hydrotherapy session? Y N
If so, how long ago
__________and where?________________________
Do you give yourself enemas? Y N
If Yes, how often? Weekly Monthly Annually
Do you take laxatives? Y N How often? Daily 3 x/week Weekly Monthly Occasionally
How long have you been taking them? ___weeks ___months ___ years
What type of laxative? Herbal Over the Counter Prescription
How often do you have a bowel movement? 1 x Week 2 x Week 3 x Week
1 x Day 2 x Day 3x Day 4 x Day OTHER:_________________
What do you hope to accomplish
with colonics?_____________________
To the Client:
AGREEMENT: “Soothing Solutions” does not provide medical services of any kind. Any procedures administered by this office are a non-medical in nature. We do not diagnose, treat or cure any disease or physical or mental human ailment or condition of any kind. Any medication or other supplementation prescribed by your physician should be continued. Any medical complaints or request for diagnosis, prescription or treatment of human ailments should be referred to your licensed physician. You should consult your doctor before beginning any new health program.
Please call within AT LEAST 12 hours if you must break an appointment.
15 minutes late to your appointment, it may need to be cancelled.
I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment for the full scheduled appointment.
I have chosen to have therapeutic treatments by “Soothing Solutions”. I understand that no specific therapeutic claim is implied or made by “Soothing Solutions” in administering these applications. I understand that if I have any doubt about doing any of the services offered by “Soothing Solutions” I should consult with my doctor first, and will not hold “Soothing Solutions” or it’s employees responsible for any unforeseen side effects, or any injuries due to treatments, accidents or any slips or falls.
I have read and understand and agree to the above statements.
All information is true to the best of my knowledge.
Client’s Signature:____________________
