Please Answer the Following Questions

Do you have a bowel motion daily? yes no

Do your bowel motions feel complete? yes no

Do you strain to evacuate? yes no

Do you suffer from Haemorrhoids? yes no

Do you leave a streak on the toilet bowel? yes no

Do you feel low in energy, tired or fatigued? yes no

Do you suffer from depression or anxiety? yes no


Do you feel : Overweight      Underweight
Happy with your weight

Do you suffer from : Eczema    Acne
Dark circles under the eyes   

Do you consume alcohol daily?  yes no

Are you a smoker? yes no

 

Do you often have more than 1 alcoholic beverage in 1 day?
yes no

Do you have any known allergies?
specify

Are you taking any prescribed medication?
specify

How many meals do you have in 1 day? 
specify

How many hours do you exercise in 1 week?
specify
 

Have you had a colorectal screen in the last 12 months?     yes no

If you are a female, are you pregnant? yes no


Full Name

Email

Phone
 

Weight  kg

Height cm 
     
Gender   
 
Age

 
 
 
Locations
 
 

 

 

 
 

Copyright: Colon Care Centre Pty. Ltd. 2003