Intake Form Name * First Name Last Name Email * Phone (###) ### #### City State 1) How did you hear about Flush 2) Have you ever had colon irrigation before? Where/When 3) How many bowel movements per day? How many each week? 4) Do you have hard or soft bowel movements? 5) Do you strain or push when going to the bathroom? 6) Why are you coming to see us today? 7) Are you experiencing any of the following; Constipation/Diarrhea/Both? Acid Reflux? Acne? Gas/Bloating? Hemorrhoids? Abdominal Discomfort? Describe any issues not listed. 8) List any medications you are taking 9) List any medical conditions you have Thank you!
