Holistic Questionnaire

Full Name* (required)

Phone

Street Address

Street Address 2

City

State

Zip Code

Email

Occupation

Marital Status
SingleMarriedPartnershipDivorcedOtherPrefer not to say

Number of Children

Birthdate

Are you under a doctor's care?
NoYes

What are you being treated for?

Doctor's Name, Office Location, and Phone

Medications

Supplements

Have you received a colonic before? If yes, when?

Have you received a lymphatic drainage massage before? If yes, when?

How many bowel movements do you have per day?

If you don't have daily bowel movements, how many do you have per week?

Do you strain to have a bowel movement?
NoYes

Does it feel complete?
NoYes

Do you use laxatives? If yes, what type and how often?

Are you currently pregnant or could you potentially be pregnant?
NoYes

What is your blood type?

List all physical complaints (please be specific)

List all surgeries (type and date concluded)

List all allergies

What do you eat for the following meals? (Please be specific)

Breakfast

Lunch

Dinner

Water intake per day (in ounces)

Exercise habits

What brings you in today? What are you hoping to resolve?

Please check any of the following health conditions that apply to you:
Congestive heart failure of organic valve diseaseRecent colonoscopy (at least the 12 days post Colonoscopy)Severe cardiac disease; e.g. uncontrolled hypertensionTumor in the Rectum or Large IntestineAneurysmRenal insufficiencyTake blood medicationKidney dialysisSevere anemiaActive aneurysmActive internal bleedingHIV/AIDSGI hemorrhage/perforationGI bandSevere hemorrhoidsEpilepsyUlcerative colitisHistory of seizuresCrohn's diseaseAbortion (less than 6 months)CirrhosisMiscarriage (less than 4 months post-op)DiverticulitisBreast feedingHepatitis A, B, CPregnancyCarcinoma of the colon or rectumCompromised immune system at present timeFissures/fistulasPresent gastrointestinal infectionAbdominal hernia / inguinal herniaRectal bleedingColon surgeryStrong abdominal painRecent abdominal surgery (at least 3 months post surgery)Vomiting at present timeRecent hernia surgeryTake medication to control diabetesTake medication to control blood pressureAny issue urinating - present or past

For Bio Electric Lymphatic Drainage:
Electrical implant of any kindPace MakerRecent surgeryPins, staples, metal platesAuto accident, falls, any other trauma to the body

Please explain anything checked above and date of last occurrence:

How did you hear about us?
Family or FriendAdFacebook AdGoogle SearchYelp

Person who referred you?

Do you want to receive Iyasu's newsletters which includes Iyasu articles and information regarding appointment availability (you can unsubscribe anytime)?
YesNo

By returning my completed questionnaire, I agree to the following:

24 Hour Cancellation Policy:*

I acknowledge Iyasu's cancellation policy. I agree to pay for any missed session in full if I cancel with less than 24 hours notice.

I also agree if I fail to show up for my appointment with no communication with Stephanie, Iyasu will not retain me as their client.

Iyasu Disclaimers:*

I acknowledge and understand the therapists at Iyasu are not physicians and do not diagnose or prescribe. I acknowledge by returning the questionnaire that Iyasu advises me to seek medical treatment by a licensed physician for any health issues I may have and Iyasu services do not take the place of medical care by a licensed physician. I have been made aware of and have disclosed to Iyasu all contraindications I have prior to receiving sessions. I have honestly answered all above questions and I am not intentionally withholding information about my health. Returning the questionnaire gives Iyasu my informed consent prior to receiving a colonic.

If you are a Federal, State or Local agent, upon entering these premises you must declare same or under the Bivens Act, Article 42, be held personally and individually liable. I have read the above and declare that I am not an agent.

I agree to inform Iyasu, Inc. prior to booking an appointment of any health issues and/or health procedures for my first visit and any subsequent visits. I agree that informing Iyasu, Inc. is my sole responsibility and understand that I may not be seen if I do not disclose this information and will hold Iyasu Inc, the owner and therapists harmless if I do not comply with this agreement prior to booking each new session.