Cleanse Questionnaire

The Austin Cleanse Retreat cleanse is specifically formulated to flush and detoxify the body the maximum amount possible in a short period of time. The products, soups and juices provided will give you nutritional support as well as cleansing support for heavy metals, parasites, pesticides and candida. I prefer participants to be at a certain level of health in order for me to facilitate you through this cleanse and for you to reap the full benefits. We will do gentle walking every day to energize and flush the system. Please let me know if this will be a problem for you. Also, I require daily or alternate day colonics to help flush toxins on out of the body so you don't reabsorb. Please let me know if you have questions about this procedure or if you feel you will be unable to do this procedure.

Please answer yes or no to these questions and if you feel the need to explain then feel free to do so.

All answers will be kept confidential. Feel free to call me at 512-825-0226

I am interested in Cleanse Retreat Date(s)


First Name


Last Name







Email Address


Please answer the following questions:

Yes No
Hepatitis C? Yes No
Diabetes Type 1? Yes No
Heart Disease or problems? Yes No
Cancer? Yes No
Radiation/Chemo Treatment? Yes No
Do you have any mental health problems? Yes No
Are you presently under a Dr's care? Yes No
Lap Band procedures?
Yes No
Severe Cardiac Disease? Yes No
Aneurysm? Yes No
Severe Anemia? Yes No
GI Hemorrhage/Perforation? Yes No
Severe Hemorrhoids? Yes No
Severe Diverticulosis? Yes No
Ulcerative Colitis? Yes No
Crohns disease? Yes No
Cirrhosis? Yes No
Presently pregnant? Yes No
Abdominal Hernia? Yes No
Recent Colon surgery? Yes No
Renal Insufficiency? Yes No
Fissures/Fistulas? Yes No
Do you have any problems walking up or down stairs? Yes No
Have you ever had a colonic? Yes No

Explain any Yes answer:

List all allergies and be specific:

Date of birth [MM/DD/YYYY]






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