Detoxification & Digestive Health Form

*First Name
*Last Name
*Email
*What are your wellness (detox) goals?	required
*Height
*Weight
*Age
*Are you pregnant?
*Have you ever had a colonic before? How many? Where did you go?	required
*Was the colon therapist in the room during your colonic? Method used?	required
*When was your last colonic?	required
*What results have you gotten in your colonics?	required
*Do you use (past or present) any of these for bowel elimination? Choose one here, type others below.
*List other bowel elimination products used. HOW OFTEN?	required
*When was your last bowel movement?	required
*How often do you have bowel movements?	required
*What is the average length / amount / diameter of your bowel movements?	required
*What is the average color / shape / odor of your bowel movements?	required
*What is the average consistency (hard or soft) of your bowel movements?	required
*Specify these or other intestinal/digestive health issue(s). (Choose one here, type others below.)
*List other intestinal/digestive health issues (specific). HOW LONG?	required
*Approximate time of dinner?
*How often do you eat out at fast food/other restaurants?	required
*Do you experience food cravings – which ones?	required
*Daily diet, average # servings: FRUIT	required
*Daily diet, average # servings: VEGETABLES (do not include dark green leafys)	required
*Daily diet, average # servings: DARK GREEN LEAFYS	required
*Daily diet, average # servings: WHOLE GRAINS	required
*Daily diet, average # servings: NUTS / SEEDS	required
*Daily diet, average # servings: SUPERFOODS / SUPERGREENS (sprouts, seaweed, spirulina, etc)	required
*Daily diet, average # servings: RED MEAT	required
*Daily diet, average # servings: PORK	required
*Daily diet, average # servings: CHIKN/FISH/TURKY	required
*Daily diet, average # servings: DAIRY (eggs, cheese, butter, milk, yogurt, etc)	required
*Daily diet, average # servings: OTHER CARBS	required
*Daily diet, average # servings: DESSERTS (also, list your favorites)	required
*Daily diet, average # servings: SODAS (also, list type)	required
*Daily diet, average # servings: COFFEE/BLACK TEA	required
*Daily diet, average # servings: HERBAL TEA (also, list type & whether organic)	required
*Daily diet, average # servings: WATER (list specific average quantity in ounces or cups)	required
*Daily diet, average # servings: FRESH VEGETABLE JUICES	required
*Daily diet, average # servings: FRESH FRUIT JUICES	required
*Daily diet, average # servings: FRESH GREEN SMOOTHIES (also, list typical ingredients)	required
*Do you drink liquids with your meals? If not, give details/reasoning.	required
*What percent of your diet is RAW and what percent is COOKED?	required
*What percent of your diet is organic?	required
*Do you chew gum?
*Are you aware of proper/improper food combining or would you like more info?	required
*Describe your typical BREAKFAST, what it may consist of.	required
*Describe your typical LUNCH, what it may consist of.	required
*Describe your typical DINNER, what it may consist of.	required
*Describe your typical SNACKS, what they may consist of.	required
*Have you ever done a fast or cleanse? Please explain how long and what type.	required
*What were the results of your fast or cleanse?	required
*Are you currently fasting or taking any internal cleansers, detox teas, weight loss aids, etc.?	required
*Do you take any of the following supplements? (Choose one here, type others below.)
*List other supplements & their brand names. (If protein powder, give source of protein.)	required
*How often do you receive professional massage therapy?	required

Detoxification & Digestive Health Form

Love Thyself Day Spa

Love Thyself Day Spa

972 644 4065