Yoni Steam Intake Form Sumbission

Yoni Steam Intake Form
Name *

First Name Last Name
Date *

Month Day Year
Date
Email *
example@example.com
Phone Number

Area Code Phone Number
Contraindications

There are times when it is not beneficial for a woman to steam. First, let’s check and make sure that you do not have any contraindications. Please mark any of the following that apply
Are you currently on your period? *
Do you currently have fresh spotting? *
Have you had spontaneous bleeding within the past 3 months? *
Have you had two periods per month in the past 3 months? *
Are you pregnant? *
If trying to conceive, are you past ovulation? *
IMPORTANT

The above "Yes" replies indicate that vaginal steaming is contraindicated. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not be performed at this time.

Do you have an infection characterized with a burning itch? *
Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button) ? *
Do you have a birth control arm implant (i.e. Nexplanon)? *
IMPORTANT

If you are using the above birth control methods vaginal steaming could cause a birth control failure. It is not recommended unless you are okay with a backup form of birth control or you are not concerned about a possible pregnancy. If you have a burning itch the warmth from the steam could be uncomfortable since there is already so much heat in that area. In this case it is best to seek treatment from an acupuncturist to get the burning sensation to go away prior to doing a vaginal steam session.
Comments:
Enter any additional information in the space provided.
Sensitivities

Some women are very responsive to steam and it can cause a physiological response. If you are in this category then it is okay to steam, however your practitioner will adjust your steam session and herbs so that it perfectly suits you.
Is this your first time doing a steam session? *
Are your menstrual cycles currently or historically every 27 days or shorter *
Have you experienced any hot flashes over the past month? *
Do you have an IUD in? *
Are you currently or historically prone to yeast infections? *
Are you currently or historically prone to bacterial vaginosis? *
Do you currently have or had: herpes, HIV/AIDS, trichomoniasis, HPV, Gonorrhea, Chlamydia, Syphilis, PID or any other type of STI? Please specify in the comments section. *
Do you have the nuva ring in? ( If so, it should be removed prior to steam session) *
Are you 13 years of age or younger? *
Do you have a history of spontaneous bleeding or 2 periods per month? (4 months or later in the past) *
Comments:
Enter any additional information in the space provided.
The above "yes" replies indicate sensitivity in which case a mild setup without a burner should be used. Under no circumstances should clients who have sensitivity use an advanced setup with a burner.
HERB SELECTION

It is best to select herbs suitable to your constitution. Your practitioner will use the info from this intake form to select a suitable vaginal steam formula for you.
Indicators for Cleansing Herbs:
Are your menstrual cycles 28 days or longer? *
Is your menstrual cycle absent or missing for any unknown reason, or because or birth control? *
Are you currently taking birth control pills? *
Do you currently have any cyst or fibroids? *

Indicators for Gentle Herbs:
Do you ever have menstrual cycles 27 days or less? *
Do you have fresh spotting between periods? *
Are you currently under the age of 13? *
Indicators for Disinfecting Herbs:
Do you have green vaginal discharge? *
Do you have yellow vaginal discharge? *
Do you have white vaginal discharge? *
Do you have thick vaginal discharge? *
Do you have malodorous vaginal discharge? *
A combination of any type of discharge with a scent.
Indicators for Moisturizing (Cooling) Herbs:
Do you have vaginal Dryness? *
Have you experienced hot flashes recently? *
Have you experienced night sweats recently? *
Do you have any type dry infection (without vaginal discharge)? *
Do you have an aversion to heat? *
Are you prone to infections or viruses? *

CAUTION SIGNS
If steaming causes a rash, bumps, headaches itchiness, diarrhea or the onset of fresh spotting or inter-period bleeding, this could be a sign that your steam protocol or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur, please let your practitioner know so they can adjust the steam session as necessary or make a referral.

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In 99% of all cases using a mild (10 minute) steam session and mild herbs will prevent any of the above signs from happening so it's very important that you give honest answers in this intake form so that the practitioner can set up a steam session that will fit your needs.

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General: I recommend that you consult with a qualified healthcare practitioner if you have any concerns using any herbal products. For educational purposes only. This information has not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

I understand that vaginal steaming may have positive or negative side effects as a result of doing a vaginal steam session. I accept legal responsibility for my choice to do a vaginal steam session and waive the responsibility of the practitioner and the facility where the steam session takes place in the case that any of the named side effects (or others) may occur.
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Yoni Steam Intake Form

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CAUTION SIGNS