Indalo Health & Wellbeing Offering you the very best in Colon Hydrotherapy and Natural Health Care in Cape Town

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Booking Form

Colonic Irrigation Questionnaire

If you have not been to Indalo Health before, please fill in this questionnaire when making a booking. Your information will be treated as confidential.

Name*
FirstLast
Telephone
Mobile
Email*
Sex
Age
Weight
Have you had colonics before?
What therapies do you use regularly?
Reasons for the treatment:
- Kick-start healthy living
- Detox
- Increase energy
- IBS/Bloatedness
- Mood swings
- Parasites
- Help with weight loss
- Diarrhoea
- Candida
- Headaches/migraines
- Irregular bowel movements
- Lack of energy
- Skin problems
- Constipation
- Food cravings
- Allergies
(tick the ones that apply to you)
Tick the statements that apply to your eating habits and lifestyle:
- I have a balanced diet
- I don’t take milk
- I smoke & drink
- I snack on sweets/chocolate
- I drink 8 glasses of water/day
- I don’t eat wheat
- I eat slowly
- I often overeat
- I exercise enough
- I eat salads/vegetables
- I eat quickly
- I have big meals after 8 pm
- I do not exercise enough
- I eat rice, barley etc
- I eat ready meals
- I often eat bread, pasta etc
Please state your occupation and describe the levels of stress, a typical workday eating pattern, including meals, snacks and liquid intake. If you smoke or drink alcohol please state how much. If you take recreational drugs please mention this to the practitioner.
Please check whether you have any of the following conditions for which this treatment is contraindicated:
- Severe Cardiac Disease
- Severe Anaemia
- Active fissures/fistulae
- Recent colorectal surgery
- Cirrhosis or abd. hernia
- Unmonitored High BP
- GI haemmorage/perf
- Pregnancy 1st trimestre
- Renal insufficiency
- Colorectal carcinoma
Please check if you have had any of the following:
- Cancer
- Diabetes
- High Blood Pressure
- Heart Disease
- Hepatitis
- Rheumatic Fever
- Thyroid Disease
- Seizures
- Other
Please add any information on operations/surgeries in the last 5 years (continue on the reverse if needed):
Please list any Medications and Nutritional Supplements you take on a daily basis
Please mention any other information you feel would be relevant to this treatment.
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ARCH – Association and Register of Colon Hydrotherapists

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