Client Intake Form
Please feel free to either complete this form online and send it to us or, if you would rather complete an offline version of the form, simply
to access a PDF copy of the form. If you elect to complete the offline version, we would ask that you please print and bring the completed form with you to the studio.
If you are completing the online form, let's start off with some basic details about you:
Reason for colon hydrotherapy:
Have you received colon hydrotherapy before?
How often do you have a bowel movement?
Do you have a family history of intestinal problems?
Have you undergone any internal surgeries?
Do you currently use any of the following? How often? (daily, number of times per week/month)
My bowel movements are:
Over the counter or prescription medications used in the last 6 months
Check all that apply now or in the past:
Describe your diet:
Are you currently undergoing any other therapies?
Please check and/or give approximate dates for all that apply:
Other symptoms, medical issues, diagnoses, or health concerns:
Colon hydrotherapy is not a recognized medical procedure in California. Colon hydrotherapy, the experience shared by the hydrotherapist, and any information provided or statements made by Health2o, its employees and/or representatives are personal opinion, and in no way meant to replace or imitate the care of a licensed health professional, to be taken as a medical fact or used to diagnose or treat disease, but as suggestions, opinions and a sharing of ideas of alternative ways of healthful living between the therapist and the client. We strongly advise anyone embarking on colon hydrotherapy to first seek the advice of their healthcare provider.
I have read and understand the disclaimer, and have filled out the questionnaire to the best of my knowledge.