|Date of Birth: *|
| / || / |
|Contact Number: *|
|E-mail Address: *|
|Do you have children?|
If so, how many?
|If woman, are you currently pregnant?|
|If so, what trimester?|
|Have you ever traveled abroad?|
|How did you hear about Lifetime Health & Consulting by Sage Joya?|
|Have you had a colonic before?|
|If so, when was your last colonic?|
| / || / |
|Where did you have your last colonic?|
Why are you switching therapist?
|Describe your experience with colon cleansing:|
|What is your reason for seeking|
Guided Colonic Therapy with Sage Joya?
|Are you under physician care for a|
|If yes, please explain:|
|Please provide physician name,|
address and contact number:
|List hospitalizations/surgeries within the past 3 years:|
|List all medications/supplements you take regularly (include over-the-counter):|
|What, if any, are your major physical complaints?|
|Mark all intestinal procedures you have experienced. |
|Please provide the date of the marked intestinal procedure above. Also, include any other intestinal|
procedure you experienced not listed above.
|How many bowel movements do you have per day?|
|Please describe your bowel movement. Be specific. Try your best to excuse embarrassment.|
This information is asked to provide solutions and support your progress.
|Do you push or strain to initiate a bowel movement?|
|Do you use a stool softener to initiate a bowel movement?|
|Do you stick any object into your rectal orifice to initiate a bowel movement? If so, what do you use?|
Please try your best to excuse embarrassment. This information is asked to provide solutions
and support your progress.
|Please explain any concerns you might have regarding your rectal orifice.|