Please enable JavaScript in your browser to complete this form.First Name *Last Name *Address *Postcode *Email *Mobile Number *Date of BirthHave You Had Colonics Before *YesNoWhat Therapies Do You Use Regularly?Is the Reason for Having This Treatment to Kick Start Healthy Living? *YesNoIs the Reason for Having This Treatment to Detox? *YesNoIs the Reason for Having This Treatment Due to Lack of Energy? *YesNoIs the Reason for Having This Treatment to Help with Mood Swings? *YesNoIs the Reason for Having This Treatment to Help with Allergies? *YesNoIs the Reason for Having This Treatment to Help with Skin Problems? *YesNoIs the Reason for Having This Treatment to Help with Irregular Bowel Movement? *YesNoIs the Reason for Having This Treatment to Help with Constipation? *YesNoIs the Reason for Having This Treatment to Help with IBS/ Bloatedness? *YesNoIs the Reason for Having This Treatment to Help with Weight Loss? *YesNoIs the Reason for Having This Treatment to Help with Food Cravings? *YesNoIs the Reason for Having This Treatment to Help with Headaches/ Migraines? *YesNoIs the Reason for Having This Treatment to Help with Yeast/ Candida? *YesNoIs the Reason for Having This Treatment to Help with Parasites? *YesNoHave these Conditions Lasted? *Over 1 Year2-3 Years5 Years or LongerIs there any more information you would like to add to this?I have a balanced diet *YesNoMost of the TimeI eat salads, veg/ raw foods *YesNoSometimesI eat quickly *YesNoI often over eat *YesNoSometimesI have large meals after 8pm *YesNoSometimesI eat ready meals/ processed food *YesNoSometimesI eat bread pasta/ lots of carbs *YesNoSometimesI eat wheat/ gluten *YesNoSome of the the TimeI eat dairy *YesNoSome of the the TimeI snack on chocolates or sweets *YesNoSome of the the TimeI chew thoroughly *YesNoI drink 8 glasses of water per day *YesNoSometimesDo you drink alcohol? *NeverOccasionallyRegularly (twice of more per week)Over Recommend intake of 14 units per weekI smoke *YesNoDo you use recreational drugs? *YesNoI exercise *YesNoOccasionallyPlease state your occupation and describe your levels of stress, a typical work day eating pattern including meals, snacks and liquid intake. *Please descibe your bowel movements including frequency, amounts and appearance *Do you/ have you had cancer of the colon or rectum *YesNoDo you have/ had any other cancer? *YesNoDo you/ have you had crohns? *YesNoDo you/ have you had ulcerative colitis? *YesNoDo you/ have you had any forms of bleeding in the GI tract? *YesNoDo you have diverticulitis? *YesNoDo you have/ had bloating? *YesNoDo you have/ had IBS? *YesNoDo you have fissures, fistulae or haemorroids? *YesNoDo you/ have you had heart disease? *YesNoDo you/ have you had un-monitored high blood pressure? *YesNoDo you/ have you had severe anaemia? *YesNoAre you within the first 3 months of pregnancy? *YesNoDo you have diabetes? *YesNoDo you have/ had rheumatmatic fever? *YesNoDo you have/ had severe headaches? *YesNoDo you have/ had thyroid disease? *YesNoDo you have/ had seizures? *YesNoDo you have/ had thrush? *YesNoDo you have/ had hepatitis? *YesNoDo you have/ had a prolapse? *YesNoPlease add any information on operations or surgery in the last 5 years *Please list any medications and nutritional supplements you take on a regular basis *Have you come into contact (within 6 feet) with someone who has officially been tested positive with COVID-19 diagnosed in the past 14 days? *YesNoIf yes to the above you will need to re-schedule your booking until you have self isolated for 14 days.Do you have any of the following: Fever, Chills, Cough, Shortness of Breath, Difficulty Breathing, Boday aches, Headache, New loss of taste/ smell, Sore Throat? *YesNoIf yes to the above you will need to re-schedule your booking until you are sympton free or have self isolated for 14 days.I confirm that I have provided to the best of my knowledge and ability the relevant information about my health and lifestyle. I agree to having a colonic hydrotherapy treatment with Catherine Hood and to inform her of any relevant changes to my health and lifestyle. I have understood the treatment that I am consenting to and confirm that I have no reason to consult with my GP before under going the treatment *YesNoI confirm that I have not omitted any information relevant to this treatment relevant to this treatment and that I agree for my information to be kept by Catherine Hood but not shared with other parties without my consent. *YesNoPRINT NAME *DATE *Where did you hear about Bodicare? *EmailSubmitBe Sociable, Share!FacebookTwitterPinterestLinkedinDigg