New Client Intake Form
Welcome to Refresh Your Soul. Please, take some time to fill out this intake form.
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Email *
First & Last Name *
Date *
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Address *
City *
Zip *
Phone (Cell) *
Phone (work) *
Email Address *
Occupation *
No. of Children *
Marital Status *
Date of Birth *
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How did you hear about us? *
Client History
Are you currently or in the last year, under a physicians care? *
If yes, please specify: *
Have you had any of these health problems in the past or at present? Please select all that apply. *
Required
List any medications and vitamins that you take regularly: *
List any known allergies:
How many bowl movements to you have daily/weekly? *
Do you  have any skin conditions pertaining to your face or body? *
If yes, please specify: *
Do you smoke? *
Have metal implants or pacemakers? *
Follow a strict diet? *
Exercise regularly? *
Have regular sleep patterns? *
Moisture Hydration
How much water do you consume daily (in ounces)? *
How many caffeinated beverages do you consume daily? *
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10
Coffee
Tea
Soda
Energy Drink
Do you take diuretics? *
How many alcoholic beverages do you consume weekly? *
Do you ever experience these conditions on your skin? *
Do you burn in moderate sunlight? *
Do you blush easily when nervous? *
Do you have a tendency to redness? *
Have you ever suffered any sinus problems? *
Nerve Activity
Do you take any stimulants or slimming tablets? *
What level do you consider your pain threshold to be? *
Have you ever experienced any claustrophobia? *
What type of massage pressure do you like? *
Clear selection
Colon Information
Have you ever had a colonic before? *
Is yes, when?
Have you ever done colon cleansing in the past? *
Do you strain to have a bowel movement? *
Do you use stool softener or laxative? *
If yes, herbal laxative or suppository? *
Do you have hemorrhoids or rectal problems? *
If yes, please specify:
Have you ever had rectal bleeding? *
If yes, please explain:
Have you ever had a colonoscopy? *
If yes, please explain:
Have you ever had Sigmoidoscopy? *
If yes, please explain:
What do you feel a colonic will do for you? *
Is there anything we should know about concerning your colon? *
What You're Eating
How many servings do you eat a week? *
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14+
Vegetables
Whole Grains
Beans
Legumes
Chicken, Fish
Fruit
Bread
Bagels
Pasta
Muffins
Baked Goods
Candy
Cake, Cookies
Red Meat, Pork
Dairy
SOy Products
Fried Foods
Stress Level
Please select, on a scale of 1-10, 1 being the least and 10 being the highest level of stress in  your life right now: *
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9
10
Column 11
Work
Family
School
Friends
Loved Ones
Kids
Personal
Illness
Money
Death
I confirm the information here is true and valid *
Required
Notice designed to comply with the State of California Guidelines in the Business and Professions Code of the State of California - Section 2053.6
All clients must read, understand, and sign this disclosure.
Colon hydrotherapy services provided at this center comply with Section 2053.6 of the Business and Professions Code of the State of California. In compliance with the code, you must be advised:
A.) There are NO licensed physicians at this center and the individual performing colon hydrotherapy is ONLY a colon hydrotherapist, they are not a physician. This means and implies that they cannot and will not:

Conduct surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
Administers or administer x-ray radiation to another person.
Prescribe or administer legend drugs or controlled substances to another person.
Recommend the discontinuance of legend drugs or controlled substances prescribed by an appropriately licensed practitioner.
Willfully diagnose and treat a physical or mental condition of any person under circumstances or conditions that cause or create a risk of great bodily harm, serious physical or mental illness, or death.
Set fractures.
Treat lacerations or abrasions through electrotherapy.
Hold out, state, indicate, advertise, or imply to a client or prospective client that he or she is a physician, a surgeon, or a physician and surgeon.

B.) Colon Hydrotherapy is alternative or complementary to healing arts services licensed by the state.

C.) The services of Colon Hydrotherapy and the Therapist that provide the services are not licensed by the state.

D.) The session of colon hydrotherapy includes the following procedures:
The client will insert and retract speculum.
Warm (temperature and pressure controlled) water will flow into the colon softening fecal material, which will be released through normal peristalsis into the sewer.
Your dignity and modesty will be maintained at all times.
The session will last approximately 30-45 minutes.

E.) The theory of treatment upon which the colon hydrotherapy is developed is more historical and intuitive than scientific as there have not been any studies to validate the effectiveness of the modality. However, many cultures and societies believe that a clean colon can enhance the health of an individual. This started thousands of years ago with the simple enema and has evolved into the present day colonic. Many people simply report feeling better after a colonic. On the other hand, there are a growing number of health care practitioners who believe in the concept of auto-intoxication, that a sluggish bowel (one that is not regular) allows the body to reabsorb toxins from the colon. This theory may or may not have validity depending on who you listen to, but we know there is an increased level of toxins in our environment and common sense tells us that anything we can do to assist the body of riding itself of toxins should have value.

F.) Any therapist working at Refresh Your Soul has been trained on all safety measures and follows I-ACT Guidelines. You may validate this information by checking with the I-ACT office at (210) 366-2888 or go to the I-ACT website at www.i-act.org and then check the referral section.

I acknowledge that I have read the above disclosure and have been given a copy of the document. This information was provided to me in a language I can read and understand.

Type your full name to consent *
Date *
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Declaration
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.
A copy of your responses will be emailed to the address you provided.
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