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Colon Hydrotherapy Questionnaire / Cuestionario de hidroterapia de colon


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Colon Hydrotherapy Questionnaire /

Cuestionario de hidroterapia de colon
All information provided in this questionnaire will be treated in the strictest confidence. / Toda la informacion proporcionada en este cuestionario sera tratada con la maxima confidencialidad.
Full Name / Nombre completo: ________________________________________________________________________________
Address: / Domicilio: ________________________________________________________________________________Telephone No: (Home) / Telefono (hogar)_____________________ MOB / Movil:___________________ Email/ correo electronico:__________________________________

Date of birth:/ Fecha de Nacimiento _______________ Age/Edad_________Height/ Altura ____________ Weight/ Peso: _______________



Occupation/ Ocupacion/Profesion: ________________________________________________________________________________
Name and address of G. P. / Nombre y domicilio de su medico de cabecera.: ________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________


Do I have your consent to contact your G.P. if necessary? / Tengo su permiso para consultar su medico si es necesario?____________________________ SI / NO
Marital Status: Single/Partner/Married/Separated/Widowed/divorced Do you have any children? / Estado civil: Solo/a/Pareja/casado/a/Separado/a/viudo/a/divorciado/a ….....Tiene hijos? ______
Are you currently receiving medical treatment from your G.P. or hospital? / Esta recibiendo actualmente medicacion de su medico u hospital? SI / NO

If yes please list condition(s) being treated: / En caso afirmativo enumerar :la condicion que se esta tratando _________________________________________________________________________

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Please list all medications you are currently taking: / Anote todos los medicamentos que esta tomando: ________________________________________________________________________

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List all past medical conditions with approximate dates: / Enumere todas las condiciones medicas anteriores con fechas aproximadas: ________________________________________________________________________________

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List all past surgical procedures with approximate dates: / Enumerar todos los procedimientos quirurgicos anteriores con fechas: ________________________________________________________________________________

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List any vitamin / mineral supplements you are currently taking: / Haga una lista de los suplementos de vitaminas/minerales que esta tomando actualmente

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Are the above prescribed or self-prescribed? / Es prescrito o es por su propia voluntad? ________________________________________________________________________________
How long have you been taking the supplements? /Cuanto tiempo lleva tomando los suplementos? ________________________________________________________________________________
Are you currently consulting any other practitioners? Please give details of treatments you are receiving: / Tiene actualmente otras consultas con otros terapeutas? Describa el tratamiento que esta recibiendo.

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Please list any herbs and / or homeopathic remedies being used: / Liste las hierbas o remedios homeopaticos usados: _____________________________________________________________

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Do you suffer from, or have you ever suffered from:/ Usted sufre de o ha sufrido de:

High blood pressure / Hipertension

SI / NO

Kidney failure / Insuficiencia renal

SI / NO

Heart Disease / Enfermedad de Corazon

SI / NO

Cirrhosis of the liver / Cirrosis del higado

SI / NO

Severe Haemorrhoids / Grave hemorroides

SI / NO

Cancer of the Colon or Rectum/ Cancer del Colon o del Recto

SI / NO

Abdominal of Inguinal Hernia / Abdominal de la hernia inguinal

SI / NO

Recent colon or rectal surgery / Reciente cirugia de colon o rectal?

SI / NO

Haemorrhage / Perforation / Hemorragia/ Perforacion

SI / NO

Severe Anaemia / Anaemia grave

SI / NO

Fissures / Fistulas / Fisuras / Fistulas

SI / NO

If you have answered YES to any of the above please give details: / Si ha contestado SI a las preguntas anteriores de detalles: ________________________________________________________________________________

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Please tick if you suffer or have suffered from any of the following conditions: / Porfavor marque la casilla si padece o ha padecido algunas de las siguientes condiciones:




General

Current/Actual

Past/ Pasado

Genito Urinario

Current/Actual

Past/ Pasado

Alcoholism/

Alcoholismo









Bladder infection / Infeccion de la vejiga







Anaemia / Anaemia







Kidney infections/stones / infeccion de rinones /piedras







Cancer (of any type) / Cancer (de cualquier tipo)







Painful urination/ dolor al orinar







Diabetes / Diabetes







Recurring Cystitis / cistitis recurrente







Dizziness/ Mareo







Muscle & Joints / Musculos y Articulaciones







Double/blurred vision/ Mirada doble o borroso







Arthritis/ Artritis







Drug addiction/ Adiccion a las drogas







Lower Back Pain/ dolor de espalda baja







Fainting spells/ Desmayos







Joint pain/stiffness / dolor en las articulaciones/ rigidez







Ear infections/ Infeccion de orejas







Multiple sclerosis / esclerosis multiple







Epilepsy/ Epilepsia







Muscle weakness / debilidad muscular







Headaches/Migraines / Dolor de cabeza/Migranas







Swollen joints / Articulaciones inchadas







Hepatitis / Hepatitis







Respiratory / Respiratorio







HIV/AIDS /

VIH SIDA









Asthma / Asthma







Hypoglycaemia /Hypoglucemia







Bronchitis / Bronquitis







ME/Encefalopatia Mialgica







Emphysema / Emfisema







Loss of weight/ Perdida de peso







Hay fever / fiebre del heno







Over-active thyroid gland/

Sobre la glandula de tiroide poco activo









Shortness of breath / Falta de aliento







Under-active thyroid gland/

en virtud de la glandula de tiroides poco activa









Sinus problems / Problema de sinusitis
















Tuberculosis / Turbeculosis







Cardiovascular/Cardiovascular







Skin / Piel







Angina / Dolor de la Angina







Acne / Acne







Poor circulation / mala circulacion







Bruise easily / moretones con facilidad







Rapid/irregular heartbeat / Latido de corazon rapido /irregular







Dermatitis / Dermatitis







Swelling of the ankles / hinchazon de los tobillos







Dryness / Sequedad
















Eczema / Eczema







Emotional / Nervous System /Sistema emotional nervioso







Fungal infections / infeciones por hongos







Anxiety / Ansiedad







Itching / Picor (comezon)







Depression / Depresion







Psoriasis / psoriasis







Fatigue / Fatiga
















Insomnia / insomnia







Woman / Mujeres







Irritability / Irritabilidad







Abortion / Aborto







Lack of concentration / falta de concentracion







Amenorrhoea (absence of periods) / Amenorrea (falta de periodo)







Lethargy / Letargo







Dysmenorrhoea (painful periods) / Dysmenorrea (periodos dolorosos)







Mood swings / cambio de humor







Endometriosis







Nervous breakdown / Agotamiento nervioso







Genital Warts / Verrugas genitales







Overreacting / Exagerando







Heavy menstrual flow / Flujo menstrual abundante







Panic attacks / attaque de panico







Hysterectomy / Histerectomia







Poor memory / poca memoria







Infertility / Esterilidad







Schizophrenia / Esquizofrenia







Miscarriage / aborto involuntario







Gastro-Intestinal







PMT(Tension Premenstrual)







Abdominal pain / Dolor abdominal







Porlapsed womb / utero prolapsado







Bad breath / mal aliento







Scant Menstrual flow / Flujo menstrual escaso







Colitis / Colitis







Too frequent periods / periodo demasiado frecuente







Constipation / Estrenimiento







Vaginal thrush / candidiasis vaginal







Diarrhoea / Diarrea







Are you pregnant? / Esta embarazada?

Si

No

Distension & Bloating of abdomen / Dilatacion y hinchazon del abdomen







If yes how many weeks? / Si - Cuantas semanas?







Diverticulitis / Diverticulosis







Date of last menstrual period:/ dia del ultimo periodo menstrual







Excecise Flatulence/ Flatulencia excesiva







Do you take the contraceptive pill or HRT? / Se toma la pildora anticonceptiva o terapia de reemplazo hormonal ??

Si

No

Gallblader disease / Enfermedad de la vesicula







Do you use an UID? / Usa dispositivo intrauterino?

Si

No

Heartburn /acidez
















Indigestion / indigestion







Men / Hombres







Irritable bowerl syndrome / Sindrome del intestino irritable







Enlarged Prostate / Agrandamiento de la prostata







Liver trouble / problemas de higado







Genital Herpes / Herpes genital







Rectal bleeding / sangrado rectal







Genital Warts / Verrugas genitales







Rectal itching/ picazon en el Recto







Impotence / Impotencia







Ulcerative Colitis /Colitis ulcerosa







Low sperm count / mobility / Bajo conteo de esperma / mobilidad







Vomiting of blood / Vomitos de sangre
















Do you have a family history of the following conditions? / Tiene un historial de familia con las siguientes condiciones?:


Crohn's Disease / Enfermedad de Crohn SI / NO

Ulcerative Colitis/ Colitis ulcerosa SI / NO

Heart disease / Enfermedad del corazon SI / NO

Cancer / Cancer SI / NO

Diabetes / Diabetes SI / NO

Asthma / Asthma SI / NO

Do you smoke? / Fuma? SI / NO How many per day? / Cuantos cigarros por dia? _________________

Do you drink alcohol? Bebe alcohol? SI / NO How many units a week? Cuantas unidades a la semana? ___________________________


Do you drink Tea? / Bebe Te? SI / NO How many cups per day? / Cuantas tazas por dia? ___________________________
Do you drink Coffee? / Bebe Cafe? SI / NO How many cups per day? / Cuantas tazas por dia? ___________________________
Do you drink softdrinks? (cola etc) / Bebe refrescos (cola etc) SI / NO How many glasses per day? / Cuantos vasos al dia? _________________________

Do you drink water? / Bebe Agua? SI / NO How many glasses per day? / Cuantos vasos al dia? _________________________


Do you exercise? / Hace ejercicios? SI / NO How often? / Cuanto? ____________ ______________________________________
Do you take recreational drugs? / Toma drogas recreativas? SI / NO What type and how often? / Que tipo y cuanto? ____________
How regular are your bowel movements? / Son sus disposiciones regulares? _______________

What is the consistency? / Cual es la consistencia? ________________

Do you feel incomplete? / Se siente incompleto/a ?________________
How many hours sleep do you get / need? / Cuantas horas duerme / necesita para dormir? ________________________________________________
Do you have a good appetite? / Tiene buen apetito? SI / NO
Do you suffer from any allergies / food sensitivities? If yes please list / Sufre de alguna alergia / sensibilidad de alimentos ? Si SI porfavor lista

SI / NO _________________________________________________________________________


do you frequently travel abroad? Viaja con frecuencia al extranjero?

______________________________________________________


Are you under lot of stress? / Tiene mucho estres ? _________________________________________________

Daily Diet / Dieta diaria
Please give an indication of your typical daily diet / Porfavor da una indicacion de como es su tipica dieta diaria.
Breakfast:/ Desayuno ______________________________________________________________________________

Mid Morning / Media manana ______________________________________________________________________________

Lunch / mediodia ______________________________________________________________________________

Mid Afternoon / Media tarde ______________________________________________________________________________

Dinner / Cena: ______________________________________________________________________________

Have you ever suffered from Anorexia or Bulimia / Ha sufrido de Anorexia o Bulimia? SI / NO


Are you vegetarian or vegan? / Es Vegetariano/a o Vegano/a? ___________________________________________

Additional Information / Informacion addicional

Please give any other information that you think is relevant / Porfavor da alguna otra informacion que piensa que es adecuado.

_______________________________________________________________________________________________________________________________________________________________

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Main reason for wanting Colon Hydrotherapy? / La razon principal por querer la hidroterapia del colon ? __________________________________________________
Recommended by / Recomendado por / Saw advertisement / vio anuncio en: : _________________________________________________________

The information provided above is, to the best of my knowledge, true and accurate. The procedure for colon hydrotherapy has been explained and I hereby give my consent for a digital examination and colon hydrotherapy to be performed on myself / my child. /

La información proporcionada la di con mi mejor conocimiento, verdadera y exacta. El procedimiento para la hidroterapia de colon se ha explicado y yo doy mi consentimiento para un examen digital y la hidroterapia de colon que se realizarán en mí / mi hijo/a.

Signature / Firma: __________________________________ Date / Dia: ____________________

THE CLINIC ADDRESS IS 5 THREE HILL VIEW GLASTONBURY SOMERSET BA6 8AU /

El domicilio de la clinica es 5 THREE HILL VIEW GLASTONBURY SOMERSET BA6 8AU

Practitioners Record / Registro del Terapeuta/ Profesional

Date / Dia

Weight (before/after) / Peso (antes / despues)

Abdominal distension / distension abdominal

Pain on examination / dolor en el examen

Scope used / insertion / ambito utilizado / insercion

Consistency / consistencia

Undigested food / alimentos no digeridos

Mucous / mocos

Gas / gases

Colour / color

Candida / candida

Parasites / parasitos

Herbs used / hierbas usadas

Implant / implante

Other Observations / Recommendations / Supplements prescribed / otras observaciones/ recommendacion/ supplementos prescritos: ________________________________________________________________________________

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