1.NEW CLIENT QUESTIONNAIRE


Full Name

First Name
Last Name

Address

Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code

Phone Number

-

Height

Weight

Date Of Birth

Marital Status

SingleMarried
Occupation

How were you referred to us?

Please check if you have ever had or done any of the following:

Colon HydrotherapyDiverticulitisPolypsColon SurgeryColonoscopyTreated for ParasitesHemorroidsRinging of the EarsDizzy SpellsChronic FatigueHIV/AIDSBarium EnemaSigmoidoscopyUlcersRectal Bleeding
Are You Pregnante?

YesNoUnsure
If yes, How Far?

Do you smoke?

YesNo
If yes, How Far?

Do you smoke?

YesNo
If yes, How Often?

Are you under a Doctor's care?

YesNo
If yes,Please Explain?

Doctor's Name

First Name
Last Name

Phone Number

-

List all allergies

List all medications and supplements:

List all major physical complaints:

I, the client listed above , am self-prescribing the
following therapies (please check all that apply):

ColonicsEar CandlingLonic Foot BathsLymphatic MassageDeep Tissue MassageReflexology

PLEASE NOTE: IF YOU ARE A FEDERAL, STATE, OR LOCAL AGENT UPON ENTERING THE INNER HEALTH CENTER PREMISES YOU
MUST DECLARE SO OR UNDER THE BIVENS ACT-ARTICLE 42 BE HELD PERSONALLY AND INDIVIDUALLY LIABLE.

We’d Love To Hear From You!!

Give us a call at: 1+(818) 881-8400 or fill out the form below, select any service(s) of interest and we’ll contact you ASAP.



Colon Hydrotherapy TreatmentRife Bio FrequencyOxygen Chamber TherapyV-SteamInfrared SaunaSteam Ozone Sauna
Ear CandlingIonic Foot BathLymphatic Drainage MassageRadio Freq. Cleanse