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FREEdom from Bloatedness

The Digestive System

The digestive system plays a vital role in health. Any imbalances there can cause several symptoms such as bloating, diarrhoea, flatulence, pain, heartburn as well as tiredness, depression, irritability, skin problems, allergies etc. However, it is valuable to investigate these symptoms and see how they can be eliminated.

Colonic Hydrotherapy can be of great benefit for the digestive system by improving bowel function and supporting health. Herbal Medicine alongside the Colonics can support and accelerate the treatment process by using either herbal implants or other herbal medicines.

In order to let us know about your condition please answer the following questions.
After emailing us your answers we’ll analyze your case and we’ll reply to you as soon as possible, making sure that we’ve got all the appropriate information. We are here to help and support you to eliminate any unwanted symptoms and feel better.

A free tea sample (mix of dried herbs) will be provided. It will contain herbs such as Dandelion, Fennel, Peppermint, Chamomile, Marshmallow or others that support the digestive process and help to relieve bloating. It will be prepared and sent to you by post or you can collect it from the clinic.

Do you suffer from Bloating?

When did it start?*:A month agoA year ago
Did something happen during that period?:
How often do you suffer from bloating?*:Every dayAll the timeOnce a weekOnce a monthOther
Do you feel bloating after eating?*:YesNo
Have you noticed anything that makes it worse or better?*:Particular foods (pasta, bread, sugar, fibre)AlcoholSmokingRelaxationExerciseUnsure
How severe is it?*:PainfulDistractingDebilatatingManageable
Do you suffer from heartburn?*:YesNoSometimes
Do you pass wind frequently?*:YesNoExcessively
How often do you open your bowels?*:Less than once a dayOnce a dayTwice a dayMore
Do you ever suffer from constipation or diarrhoea?*:YesNo
What is the consistency of your stools?*:FormedLooseDry, hard
Is it ever itchy or sore around the anus area?*:YesNo
If you answered yes to the above, have you ever had worms?:YesNo
What is your energy level?*:TiredRefreshed
Do you suffer from any allergy or food intolerance?*:YesNo
What is your diet like for Breakfast?*:Don't eat breakfastCereal / ToastFull EnglishFruitOther
What is your diet like for Lunch?*:Don't eat lunchSmall Healthy mealFast FoodLunch is my main meal of the dayFruitSandwichOther
What is your diet like for Dinner?*:I don't eat dinnerI eat a later dinner (after 20.00)HealthyLots of carbs (potatoes / pasta / bread)LargeOther
Do you snack?*:YesNo
If you answered Yes to the above, do you:Snack on FruitChocolate / Crispsother
How many portions of fruits/vegetables (fresh and cooked) do you eat per day?*:None1-34-67-10More
How much bread (slices/baguettes) do you eat per day?*:None1-34-6More
What type of bread do you eat?*:WhiteWholemealSeeded
What is your daily water intake?*:None1-2 pints3-4 pints5+
Do you drink coffee or tea?*:I don't1-3 cups4-6 cups7+
How much alcohol do you drink a week on average?*:I don't1-2 pints per week3-4 pints per week5+1-2 glasses per week (wine etc)3-4 glasses per week (wine etc)5+
How much do you smoke per day?*:I don't smoke1-56-1011-2021+
Are you taking any medication (prescribed/over the counter/alternative)?*:YesNo
If yes, please state name and dosage.:
If you take supplements, which?:
Is there anything else you would like to add that you think may be relevant?:
Title*:MrMrsMissMs
First Name*:
Surname*:
House Number / Name*:
Address 1*:
Address 2:
Address 3:
Town / City*:
Post Code*:
Tel No.:
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