Medical Questionnaire

First Name *

Last Name *

Address *

Postcode *

Email *

Mobile Number *

Date of Birth

Have You Had Colonics Before *

Yes
No

What Therapies Do You Use Regularly?

Is the Reason for Having This Treatment to Kick Start Healthy Living? *

Yes
No

Is the Reason for Having This Treatment to Detox? *

Yes
No

Is the Reason for Having This Treatment Due to Lack of Energy? *

Yes
No

Is the Reason for Having This Treatment to Help with Mood Swings? *

Yes
No

Is the Reason for Having This Treatment to Help with Allergies? *

Yes
No

Is the Reason for Having This Treatment to Help with Skin Problems? *

Yes
No

Is the Reason for Having This Treatment to Help with Irregular Bowel Movement? *

Yes
No

Is the Reason for Having This Treatment to Help with Constipation? *

Yes
No

Is the Reason for Having This Treatment to Help with IBS/ Bloatedness? *

Yes
No

Is the Reason for Having This Treatment to Help with Weight Loss? *

Yes
No

Is the Reason for Having This Treatment to Help with Food Cravings? *

Yes
No

Is the Reason for Having This Treatment to Help with Headaches/ Migraines? *

Yes
No

Is the Reason for Having This Treatment to Help with Yeast/ Candida? *

Yes
No

Is the Reason for Having This Treatment to Help with Parasites? *

Yes
No

Have these Conditions Lasted? *

Over 1 Year
2-3 Years
5 Years or Longer

Is there any more information you would like to add to this?

I have a balanced diet *

Yes
No
Most of the Time

I eat salads, veg/ raw foods *

Yes
No
Sometimes

I eat quickly *

Yes
No

I often over eat *

Yes
No
Sometimes

I have large meals after 8pm *

Yes
No
Sometimes

I eat ready meals/ processed food *

Yes
No
Sometimes

I eat bread pasta/ lots of carbs *

Yes
No
Sometimes

I eat wheat/ gluten *

Yes
No
Some of the the Time

I eat dairy *

Yes
No
Some of the the Time

I snack on chocolates or sweets *

Yes
No
Some of the the Time

I chew thoroughly *

Yes
No

I drink 8 glasses of water per day *

Yes
No
Sometimes

Do you drink alcohol? *

Never
Occasionally
Regularly (twice of more per week)
Over Recommend intake of 14 units per week

I smoke *

Yes
No

Do you use recreational drugs? *

Yes
No

I exercise *

Yes
No
Occasionally

Please 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 *

Yes
No

Do you have/ had any other cancer? *

Yes
No

Do you/ have you had crohns? *

Yes
No

Do you/ have you had ulcerative colitis? *

Yes
No

Do you/ have you had any forms of bleeding in the GI tract? *

Yes
No

Do you have diverticulitis? *

Yes
No

Do you have/ had bloating? *

Yes
No

Do you have/ had IBS? *

Yes
No

Do you have fissures, fistulae or haemorroids? *

Yes
No

Do you/ have you had heart disease? *

Yes
No

Do you/ have you had un-monitored high blood pressure? *

Yes
No

Do you/ have you had severe anaemia? *

Yes
No

Are you within the first 3 months of pregnancy? *

Yes
No

Do you have diabetes? *

Yes
No

Do you have/ had rheumatmatic fever? *

Yes
No

Do you have/ had severe headaches? *

Yes
No

Do you have/ had thyroid disease? *

Yes
No

Do you have/ had seizures? *

Yes
No

Do you have/ had thrush? *

Yes
No

Do you have/ had hepatitis? *

Yes
No

Do you have/ had a prolapse? *

Yes
No

Please 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? *

Yes
No

If 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? *

Yes
No

If 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 *

Yes
No

I 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. *

Yes
No

PRINT NAME *

DATE *

Where did you hear about Bodicare? *

Medical Questionnaire

Professional Accreditation

Catherine Has Also Worked At:

Synergy Elite Health Shop