Holistic Questionnaire

Maximum Courage 2d LogoLHCALL INFORMATION IS CONFIDENTIAL.

PLEASE FILL IN THIS INFORMATION TO THE BEST OF YOUR ABILITY.

THIS IS A SECURE TRANSMISSION MANAGED BY SAGE JOYA

Date: *
Name: *
Sex: *
Date of Birth: *
 /  / 
Address: *
Contact Number: *
-
E-mail Address: *
Occupation:
Marital Status:
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
specific ailment?
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):
List all known allergies
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.

INTESTINAL COMPLAINTS YOU HAVE EXPERIENCED

Mark all intestinal complaints:
Please provide any additional information regarding your intestinal complaints.

PHYSICAL, MENTAL, EMOTIONAL CONDITIONS OF YOUR BODY

Mark all physical, mental and emotional conditions:
Please provide any additional information regarding your physical, mental or emotional conditions.

ORDINARY FOOD AND DRINK CONSUMPTION

Indicate your true dietary intake. If you recently changed your diet, please indicate your previous dietary intake:


Briefly describe your daily dietary intake. If you recently switched diets, please describe your former eating habits:

What do you eat for breakfast?
What do you eat for lunch?
What do you eat for dinner?
What are your favorite snacks?
Do you have food cravings?
What are your favorite "crave" foods?

CONTRAINDICATIONS, RATES, POLICY AND DISCLAIMER FOR GUIDED COLONIC THERAPY

It is an honor to bring you professional and compassionate service while you are in my care. To ensure your safety and maintain the highest standards of practice, listed below are the contraindications, Guided Colonic Therapy rates and policy for your review prior to receiving services. Please email lifetimehealth@colonlove.com with any questions. Thank you.

CONTRAINDICATIONS FOR COLON HYDROTHERAPY

IF YOU HAVE ANY OF THE FOLLOWING CONDITIONS, A PRESCRIPTION FROM YOUR MEDICAL PROVIDER IS REQUIRED FOR SERVICE.  WHILE YOU ARE ULTIMATELY RESPONSIBLE FOR YOUR HEALTHCARE CHOICES, YOU ARE ENCOURAGED TO SHARE THIS LIST WITH YOUR PRIMARY HEALTHCARE PROVIDER FOR REVIEW AND APPROVAL.

SEVERE HEMORRHOIDS


SEVERE ANEMIA
ANEURYSM


PREGNANCY
CROHN'S DISEASE


CIRRHOSIS OF THE LIVER
SEVERE DIVERTICULITIS


CARCINOMA OF THE COLON
CONGESTIVE HEART FAILURE


RENAL INSUFFICIENCY
SEVERE ULCERATIVE COLITIS


FISSURES/FISTULAS
GI HEMORRHAGE/PERFORATION


ABDOMINAL HERNIA
RECENT COLON SURGERY (LESS THAN 3 MONTHS)


UNCONTROLLED HYPERTENSION


GUIDED COLONIC THERAPY SESSION RATES

New Client
New Client (.5 Hour Consultation + 1 Hour Session)$    250
New Client (.5 Hour Consultation + 1 Hour Session) SENIOR/STUDENT$    245
New Client Series of 5 Sessions
(.5 Hour Consultation + 1 Hour Session + 5 Additional Sessions)
$ 1,080
New Client Series of 10 Sessions
(.5 Hour Consultation + 1 Hour Session + 10 Additional Sessions)
$ 1,830
New Client Series of 20 Sessions
(.5 Hour Consultation + 1 Hour Session + 20 Additional Sessions)
$ 3,230
New Client Colonoscopy Prep
(.5 Hour Consultation + 1 Hour Session + 2 Additional Sessions)
$    600
Returning Client
One-Hour Session$    175
One-Hour Session SENIOR/STUDENT$    170
Series of 5 Sessions$    850
Series of 10 Sessions$ 1,600
Series of 20 Sessions$ 3,000
Colonoscopy Prep (2 Sessions)$    350
Series of 6 Sessions - ADVANCED$ 1,590
Series of 10 Sessions - ADVANCED$ 2,550


PLEASE NOTE:  All new clients to Lifetime Health & Consulting by Sage Joya must have a
new client session regardless of previous experience.  Thank you for respecting the policy.

YOU ALSO UNDERSTAND AND AGREE TO THE FOLLOWING:

  • ALL SERIES SESSIONS MUST COMPLETE WITHIN 6 MONTHS OF PURCHASE DATE                                                  (A committed client will complete a series purchase within 3 months or less)
  • SERIES ARE NON-TRANSFERABLE
  • REFUNDS ARE NOT AVAILABLE FOR SERIES
  • A 24-HOUR NOTICE IS REQUIRED TO CANCEL AN APPOINTMENT
  • A LESS THAN 24-HOUR CANCELLATION NOTICE IS SUBJECT TO A 100% MISSED APPOINTMENT FEE
  • THE RETURNED CHECK FEE IS $50
  • ALL COLONOSCOPY PREPARATION SESSIONS REQUIRE THREE CONSECUTIVE SESSIONS

DISCLAIMER:

GUIDED COLONIC THERAPY IS NOT INTENDED TO REPLACE THE RELATIONSHIP WITH YOUR PRIMARY HEALTH CARE PROVIDERS.  THE CONSULTATION IS NOT INTENDED AS MEDICAL ADVICE.  THE CONSULTATION IS DESIGNED TO COLLECT INFORMATION YOU PROVIDE ABOUT YOUR HEALTH HISTORY FOR KEEPING YOU SAFE.  FAILURE TO LEAVE OUT PERTINENT INFORMATION COULD INITIATE UNDESIRED RESULTS.  PLEASE REMAIN MINDFUL IN PROVIDING CONCLUSIVE INFORMATION WITHIN THE QUESTIONNAIRE.  THE CONSULTATION IS ALSO A SHARING OF KNOWLEDGE AND INFORMATION FROM SAGE JOYA'S EDUCATION, RESEARCH, EXPERIENCE, ESOTERIC GUIDANCE, PERSONAL EXPERIENCE AND HOLISTIC COMMUNITY.  AS A SAGE, INSTRUCTOR AND CERTIFIED COLON HYDROTHERAPIST, SAGE JOYA ENCOURAGES YOU TO REMAIN OPEN TO NEW INFORMATION ON THE EFFECTIVENESS OF GUIDED COLON HYDROTHERAPY THROUGH THE NERVOUS SYSTEM AND THE FOUNDATIONAL ROLE OF DIET, EXERCISE, SUPPLEMENTATION, STRESS MANAGEMENT AND EMOTIONAL HEALING.  SAGE JOYA ENCOURAGES YOU TO MAKE YOUR OWN HEALTH CARE DECISIONS BASED UPON YOUR RESEARCH, PERSONAL EXPERIENCE AND PARTNERSHIP WITH YOUR PRIMARY HEALTH CARE PROVIDERS.  THE INFORMATION AND SERVICES PROVIDED ARE NOT USED TO PRESCRIBE, RECOMMEND, DIAGNOSE OR TREAT A HEALTH PROBLEM OR DISEASE.  IT IS NOT A SUBSTITUTE FOR MEDICAL CARE.  IF YOU HAVE OR SUSPECT YOU MAY HAVE A MEDICAL CONDITION, YOU SHOULD CONSULT YOUR PRIMARY HEALTH CARE PROVIDERS.  THANK YOU.

PRINTED SIGNATURE OF CONSENT: *
DATE OF CONSENTING SIGNATURE: *