Colon Therapy

Patient Questionnaire

Name_________________________________________________________________ Date__________________________

Address________________________________________________ City__________________ St______ Zip____________

Phone (Home)______________________________ Work____________________________ Cell______________________

Email Address____________________________________________________________ Male/Female________________

Occupation___________________________________ Place of Employment______________________________________

Height___________________ Weight______________ Date of Birth_______/_________/_________ Age______________

Marital Status____________________________ Who is responsible for this account_______________________________

Have you ever received Colon Hydrotherapy?__________ If so, how many?___________ How Often?_________________

Over what period of time?_____________ Where?______________________________ Date of last therapy_____________

Do you use: (Please indicate heavy, moderate, light, or none)

Coffee/Tea _________ Alcohol ________ Exercise ________ Recreational Drugs __________
Soda _________ Anxiety ________ Rest ________ Stress Release __________
Tobacco _________ Dieting ________ HIV* ________ Meditation __________

Check any of the following in the last thirty (30) days with a √ or In the Past with an X

_____ Recent Constipation _____ Family History of Colon Cancer _____ Heart Disease
_____ Chronic Constipation _____ Underweight _____ Cancer
_____ Diarrhea _____ Overweight _____ Candida
_____ Parasites _____ Diabetes _____ Body Odor
_____ Colitis _____ High Cholesterol _____ High Blood Pressure
_____ Ulcerative Colitis _____ Heartburn _____ Low Blood Pressure
_____ Bowel Impaction _____ Obesity _____ Dizziness
_____ Hemorrhoids _____ Frequent Headaches _____ Fainting Spells
_____ Diverticulitis _____ Migraine Headaches _____ History of Seizures
_____ Bloody/Black Stools _____ Nervousness _____ Bloating
_____ Fistula or fissures _____ Insomnia _____ Hepatitis
_____ Ulcers _____ Irritability _____ Shortness of Breath
_____ Hernia _____ Anemia _____ Chronic Cough
_____ Crohn’s Disease _____ Arthritis _____ Emphysema
_____ Abdominal Pain _____ Painful Menstruation _____ Bronchitis
_____ Vomiting _____ Vaginal Discharge _____ Asthma
_____ Change in Stool _____ Breast Pain _____ Poor Circulation
_____ Gas, Belching _____ Fatigue _____ Enlarged Thyroid
_____ Low Blood Suger _____ Depression _____ Double/Blurred Vision
_____ Kidney Failure _____ Painful Urination _____ Bruise Easily
_____ Kidney Infection or Stones _____ Gallbladder Disease _____ Skin Dryness
_____ Prostate Trouble _____ Liver Problems _____ Skin Rash
Colon Therapy Questionnaire
Page 2

Are you now under a doctor’s care?_____ if so, please explain__________________________________________________

Doctor’s name_______________________________________________________ Telephone________________________

Major physical complaint__________________________________________________________________________________

List all known allergies____________________________________________________________________________________

List any surgeries_________________________________________________________________________________________

List all medications and supplements ou now take regularly (include over-the-counter)_______________________________

_______________________________________________________________________________________________________

Are you pregnant?__________ If so, what trimester?____________ How many bowel movements per day?____________

Do you have to strain to have a bowel movement?_______________ Do you use a stool softener?_____________________

Do you use an herbal laxative?_________ Do you use suppositories?_________ Do you have hemorrhoids?____________

Have you had bleeding from any other bodily orifice?_______ If yes, please describe________________________________

What would you like to receive from this appointment for hydrotherapy?____________________________________________

_______________________________________________________________________________________________________

Colon hydrotherapy is a safe and effective method of cleansing your large intestine (colon). Your therapist does not diagnose
disease or prescribe medication. It is your responsibility to provide pertinent health information and to inform the therapist of
any changes

RELEASE: I understand and agree that Colon Hydrotherapy services provided by this State Certified Colon Hydrotherapist are
provided pursuant to and in accordance with the laws of the State of Florida governing Colon Hydrotherapy and that full and
complete medical history disclosure is essential in providing such therapy. I agree to hold harmless, release and indemnify this
State Certified Hydrotherapist. By signing this release, I hereby declare that I have provided this State Certified Colon
Hydrotherapist with all relevant information necessary for the proper application of Colon Hydrotherapy and I expressly give my
permission for this State Certified Colon Hydrotherapist to provide such therapy.

Our colon therapist keeps a very full and tight schedule. Late cancellations and no shows disrupt our ability to service
the therapy needs of other patients. Therefore, we have adopted a new cancellation policy for colon therapy patients.
FAILURE TO GIVE 24 HOURS NOTICE OF CANCELLATION OF AN APPOINTMENT WILL RESULT IN A
BILLING FEE OF $25.00 FOR THE FIRST TWO OCCURRENCES AND FULL PRICE FOR THE GOING RATE OF
A COLON THERAPY SESSION FOR EACH OCCURRENCE THEREAFTER.

___________________________________________________________________ ____________________________
Signature Date

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 RESPONSIBLE.
 Colon Therapy
Informed Consent

I, the undersigned, authorize Utopia and its certified and licensed Colon Therapists, to
administer Colon Therapy sessions. As with any procedure, there are potential benefits
and risks associated with it. I understand how Colon Therapy is performed and used, and
I acknowledge the potential benefits and risks of it as described below:

• Colon Therapy (or a colonic) is a gentle, purified water-washing of the large

intestine. The client lies on a massage table and, with a Colon Therapy
instrument, purified and triple-filtered water is run very slowly into the colon by
the therapis. When slight pressure builds up in the colon, the practitioner reverses
the water flow to empty. As the water and waste are flowing out through an
illuminated glass viewing tube, the abdominal area is massaged. This process is
repeated several times during the period for 45-50 minutes. During one session, a
total of approximately 2-5 gallons flows into and out of the large intestines.
Utopia uses a closed Colon Therapy system with single-use, disposable speculum
and tubing.

• The Colon Therapist is always present in the room with the client during each
session.

• Colon Therapy may be used to cleanse the colon by removing fecal material, gas,
and mucus. It may also be prescribed by a physician in preparation for the
diagnostic study of the large intestine or for other conditions.

• Potential risks may include possible aggravation of symptoms existing prior to the
session, appetite changes, or energy changes.

• Possible contraindications are: severe cardiac disease, severe anemia, GI

hemorrhage/perforation, cirrhosis, carcinoma of the colon, fissures/fistulas,
advanced pregnancy, abdominal hernia, and renal insufficiency. If you have any
of these conditions or are taking certain medications, you must consult Dr. Garcia
or your physician first.

• Your colon therapist will review your questionnaire at the first visit before you
receive Colon Therapy to determine whether or not this procedure is appropriate
for you.
 » I affirm that I understand the purpose and potential benefits of Colon Therapy.

» I understand and freely accept the potential risks of the procedure.

» An offer has been made to answer any questions I have about the procedure.

» I freely and voluntarily consent to the above procedure.

» I realize that no guarantee has been offered by Utopia as to the results that may be
obtained through Colon Therapy.

» I hereby release the Colon Therapist, Carlos Garcia, MD, and Utopia, Inc. from any
and all liability which may occur in connection with the above mentioned procedure.

» I understand that I am free to withdraw my consent and to discontinue participation

in this procedure at any time.

» I am not acting as an agent for any government agency, law office, or

pharmaceutical company.

Signature of Patient (or of Guardian if under age 18):

_______________________________________________ _____________________
Signature Date