Colon Hydrotherapy Contraindications Questionnaire






    Contraindications Questionnaire To Determine Your Eligibility for Colon Hydrotherapy Session
    These standards are meant as general guidelines. Because each person has a unique medical history, you should consult your physician to determine if you are healthy enough to undergo colon hydrotherapy. Persons with certain medical conditions (contraindicated conditions) are prohibited from undergoing colon hydrotherapy.

    These conditions include the following:

    Contraindicated conditions (Not eligible for Colonic)

    • Kidney Dialysis

    • Pregnancy

    • Aneurysm

    • Congestive Heart Failure (e.g. Organic Valve Disease)

    Persons with certain medical conditions (contraindicated conditions) need approval from and/or by prescription from their physician.

    Conditions by prescription only

    • Anemia: Contraindicated if a patient is already at risk of cardiac compromise due to Anemia. They may experience worsening of their Anemia due to secondary fluid absorption through the large intestine.

    • Carcinoma: Contraindicated when Carcinoma is located in the rectum or large intestine.

    • Crohn’s Disease: Contraindicated when advanced.

    • Ulcerative Colitis: (Severe) Contraindicated only when active or bleeding.

    • Diverticulitis: (Severe or Acute) Due to (current infection) the inflamed colonic mucosa of the intestinal wall has a heightened chance of perforation due to water pressure thus creating a contraindication.

    • Epilepsy/Seizures: Contraindicated when uncontrolled.

    • Fissures/Fistulas: Contraindicated if painful and bleeding.

    • GI Hemorrhage/Perforation: Contraindicated if intestinal perforation.

    • Hemorrhoids: Contraindicated when excessive bleeding is present.

    • Hernia: (Incarcerated Abdominal) Contraindicated if painful.

    • Prostatitis: Contraindicated when acute

    • Surgery: (Recent Abdominal) Contraindicated within 6-months post-surgery: Colon, Rectum, or other abdominal surgery.

    • Tumors: Contraindicated when it is located in the Rectum or the Colon.

    My signature below indicates I have read the above and do not have any of the contraindicated conditions.

    ** Reminders **

    Please stop eating 2 hours prior to your appointment and stop drinking 1 hour prior to your appointment.

    Download Questionnaire
    DISCLAIMER The information is presented for educational purposes only and is not intended to diagnose or prescribe for any medical or psychological condition, nor to prevent, treat, mitigate or cure such conditions. The information contained herein is not intended to replace a one-on-one relationship with a doctor or qualified healthcare professional. Therefore, this information is not intended as medical advice, but rather a sharing of knowledge and information based on research and experience. Cleanse Colon Hydrotherapy encourages you to make your own health care decisions based on your judgment and research in partnership with a qualified healthcare professional. These statements have not been evaluated by the Food and Drug Administration. The information on this website is not intended to diagnose, treat, cure or prevent any disease. This notice is required by the Federal Food, Drug and Cosmetic Act.