Colonic Intake Form - Thrive Therapies

Colon Hydrotherapy Intake Form

Today's Date

Personal Details

Kia Ora! Let’s start with the basics. All information is kept strictly confidential!

First Name

Last Name

Phone number

Date of Birth

Gender

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Contact Person name & Phone number

How did you hear about Thrive Therapies?

Referred by:

Travel & Recent Health Information

Have you been overseas in the last 3 months?

Yes

If so, where?

Have you had COVID-19?

Yes

Have you received a COVID-19 vaccination?

Yes

Your Wellness Journey

Main reason for your visit/symptoms/concerns:

Have you had Colon Hydrotherapy before?

Yes

Have you had a Colonoscopy?

Yes

Are you currently under a doctor’s care?

Yes

Recent hospitalisations, surgeries, traumas, or injuries:

Medical Details

Are you taking any medications?

Do you have any allergies?

Daily Water Intake

Consumed excess alcohol or drugs in the last 24–48 hours?

Yes

Other therapies you’re currently receiving:

Herbs or supplements you take:

How would you describe your typical diet?

Were you born vaginally?

Yes

Were you breastfed as a child?

Yes

Digestive Diseases & Disorders

This helps me understand your digestive history—no judgment, just support!

Have you been diagnosed with any digestive diseases or disorders?

Yes

Please share anything else about your digestive health that I should know:

Major Diseases or Imbalances

Please share anything else about your health history, or anything you feel is important for me to know:

Bowel Health

If your bowel movements are different from the “ideal” (medium brown, smooth, toothpaste-like, 10–30cm, minimal odor/gas), please tick any that apply:

Large and lumpy

Medium width with cracks

Very soft/unformed

Liquid

Small, hard pellets

Fluffy but small pieces

Thin and smooth

Other

How often do you have a bowel movement?

Do you feel fully emptied afterwards?

Yes

Any straining to have a movement?

Yes

Constipation

Yes

Diarrhea?

Yes

Alternating constipation/diarrhea?

Yes

Bloating?

Yes

If so... Where do you feel bloated exactly?

Gas or Wind?

Yes

If so... is it very smelly gas or just air?

Reflux?

Yes

Hemorrhoids?

Do you take laxatives?

Yes

Goals & Wellbeing

What are your goals or intentions for your colonic session?

Where is tension most evident in your body?

What is your stress level on a scale from 0 to 10?

Are you currently menstruating?

Yes

Anything else I should know, medically or otherwise?

Any questions for me?

Consent & Confidentiality Statement

I consent to Thrive Therapies using AI tools for these purposes—assisting with communication and administrative tasks related to my intake forms and email/messages, including analysing, organising, and summarising my provided information to help prepare clearer written responses and correspondence. I understand this support is intended to improve efficiency and clarity, and is a helpful assistant and not a replacement for Shanti Smith’s care, professional knowledge, or the Thrive Therapies services I receive, and any information shared is confidential and used only to support my care and wellness journey at Thrive Therapies. If you have any concerns or questions, please let Shanti know.

Informed Consent

I confirm I have shared any important medical information with Shanti Smith of Thrive Therapies. I understand the colon hydrotherapy procedure, the equipment used, and possible side effects. All my questions have been answered, and I agree to participate in this session.

I acknowledge that colon hydrotherapy is not a substitute for medical treatment or advice, nor is it intended as a cure. It is a gentle method of cleansing and hydrating the large intestine. While benefits are possible, no specific outcomes are guaranteed.

Any risks or contraindications have been discussed with me. I have chosen this service for myself and take full responsibility for my health decisions. If I am under a doctor’s care, pregnant, or have serious bowel conditions, I understand I should consult my physician.

Any advice or information given by Shanti is for educational purposes only, not diagnosis or prescription. I am responsible for my own healthcare choices.

By signing below, I confirm I have read and understoodd this consent, and agree to proceed with colon hydrotherapy. I release Shanti Smith of Thrive Therapies and the facility from liability relating to this and future treatments. I understand that Thrive Therapies and Shanti Smith are not responsible for outcomes related to any treatments, suggestions, recommendations, or herbal formulas, now or in the future.

All information is confidential.

This consent form is based on current best practices for holistic therapies in New Zealand.

Type your full name here to agree to the informed consent

I consent to have this website store my submitted information so Shanti can respond to my inquiry and provide personalized care.

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