thebox:V'Jinga Steam Intake Form

Yoni Steam Intake Form
Practitioner Name

Facilitator
Practitioner Email
Client Name

First NameLast Name
Client Email
example@example.com
What is your Date of Birth?
Age
Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
Are there any herbs/food that you are allergic to? Please list them here or simply type "none" if you have no allergies.
Contraindications
There are times when it is not beneficial for a woman to steam. First, let's check and make sure that you don't have any contraindications. to edit this text...

Please Mark Any of the Following that Apply

	Yes	No	Not sure
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?
If trying to conceive are you past ovulation or IUI/IVF transfer?

Please Provide Further Information for Responses that are "Yes" or "Not Sure"
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.
What age were you at your first menstrual cycle?*
Where are you in the life stage of your cycle?*

Cycle not yet startedMonthly Menstrual CyclePeri- MenopausalMenopausalPost MenopausalFull HysterectomyPost Partum - Cycle not yet returnedPost Partum - Cycle has returned
Do you suffer from menstrual cramps? If so please check all that apply.*

cramps at ovulationcramps prior to flowcramps during flowno crampspost partum not bleeding yet
Please indicate the typical length of only your bleeding days.*
Please indicate the length of your typical monthly cycle. Your monthly cycle is how long it is from the first day of a bleed to the day before your next bleed.*

varying monthly cycle length21 day monthly cycle or less22-23 day monthly cycle24-25 day monthly cycle26-27 day monthly cycle28-30 day monthly cycle31 days or longer cycledon't know my cycle lengthNo Menstrual Cycle
Please describe your flow. ( Light, Medium, Heavy, Etc...) If you do not have one, simply put N/A*
****If you selected varying cycle length or don't know my cycle length or bleed length please expand/describe. Include approximate shortest and longest cycle length.
Do you have skipped bleeds or suffer from Amenorrhea*

yesno
Do you feel your cycle can prevent you from your normal day to day routine?
What is the color of your blood, please select all that apply.*

red onlybrownblackpink and red onlyclots during flowstringy bloodbrown blood at start of flowbrown blood at end of flowshades of red and brownbright red spotting during monthbrown spotting during monthpost partum not bleeding yetN/A
What type of Menstrual Products do you currently use?*
Do you currently experience any of the following symptoms during your monthly cycle? Please check all that apply*

night sweatshot flashestender breastsabdominal bloatingswollen feetPMSmood SwingsconstipationNo Menstrual Cycle at this time
Do you experience any of the following below? please check all that apply.*

IncontinenceOccasional leakage(ie. sneezing, coughing)Bladder ProlapseUTI/bladder infectionWake to urinate during nightUrinate frequentlyLow muscle toneNone of the above
In regard to your bowel please check all that apply.*

ConstipationPainful bowel movementHemorrhoidsBlood w/ bowel movementRectal prolapseNone of the above
In regard to vaginal discharge/fluid please check all that apply.*

WhitishYellowishGreenishBlood tingedFeminine OdorNone of the abovePost Partum not bleeding yet
Please check all physical conditions that you are currently experiencing.

PCOSEndometriosisCystsFibroidsSTDCervical DysplasiaCervical cancerUterine cancerOvarian cancerUterine ProlapseBladder ProlapseHysterectomyBirth TraumaYeast Infection/CandidaAbnormal Pap SmearsAdhesions/Scar TissuePainful IntercourseLow LibidoUTIIncontinenceWake in the night to urinate
Please check any of the following conditions that you experience on a regular basis, although perhaps not currently.*

Yeast infection/CandidaFrequent UTI'sFungal InfectionDiarrheaConstipationnone of the above
Check any health conditions that apply to you.

headachesmigrainesdizzy spellsprone to faintinghigh blood pressurelow blood pressurediabetesheart conditionOther
Do you consider yourelf to be... (check all that apply)**

chilly; often feel coldsensitive to temperature changefrequent cold hands and feetheatyover heat easilynone of the above
Please List Current Medications

Please Mark Any of the Following that Apply

	Yes	No	Not Sure
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)?

Please Mark Any of the Following that Apply

	Yes	No	Not Sure
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.
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.

Please Mark All That Apply

	Yes	No	Not sure
Is this your first time doing a steam session?
Are your menstrual cycles currently or historically ever 27 days or shorter?
Have you experienced any hot flashes over the past month?
Have you experienced any night sweats 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 have herpes?
Do you have the nuva ring in? (If so, it should be removed prior to steam session)
Are you age 13 or younger?
Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)?
Are you currently or historically prone to urinary tract infections (bladder infections)?
Do you currently have a STI or STD?

The above "yes" replies indicate sensitivity in which case a mild setup which should be performed 10-15 minutes.Under no circumstances should clients who have sensitivity use an advanced setup which is 25- 30 minute steam sessions.
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 Restore/Cleansing Herbs

	Yes	No
Are your menstrual cycles 28 days or longer?
Is your menstrual cycle absent or missing for an unknown reason or because of birth control?
Are you currently taking birth control pills?

Indicators for Align/Gentle Herbs

	Yes	No
Do you ever have menstrual cycles 27 days or less?
Do you have fresh spotting between periods?
Are you currently underage 13?

If there are any "Yes" signs for the Align/Gentle herbs this formula will always be the best choice.

Indicators for Detox/Disinfecting Herbs

	Yes	No	Sometimes
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?

Indicators for Rebalance/Cooling Herbs

	Yes	No
Do you have vaginal dryness?
Have you experienced hot flashes recently?
Have you experienced night sweats recently?
Do you have any type of dry infection (without vaginal discharge)?
Is the weather currently very hot?
Do you have an aversion to heat?
Do you radiate heat?

Cloaking
When steaming it is often commonplace to wear a cloak or steam gown. Cloaking helps to increase the benefit of the treatment by enhancing the detoxification of the session. A couple notes of caution -first, it is not advised to use plastic as a cloak as it may release toxins when heated. Second, cloaking is not a good idea if you already have excess heat in your body. Let's check to see if you have any signs of excess heat.

Mark All Excess Heat Indicators that Apply

	Yes	No
Do you have hot flashes?
Do you have night sweats?
Do you radiate heat?
Are you prone to infections or viruses?
Is it hot weather?
Do you have an aversion to heat?

Yes answers indicate excess heat in which case cloaking is not necessary. Instead use a towel, light robe, steam gown, summer dress or light wrap-around fabric.
Do You Have Any Questions or Hesitations Prior to Your Vaginal Steam Session?
Do you wish to expand on anything or is there anything else important that you feel we should know? If so please use the space provided below.
Would you like to take a photo for promotional use only for Thebox:V'Jinga Holistic Spa?

Yes, SureSure, but don't tag meI'll take my own picture (don't forget to tag me @thebox:vjinga)No photos please
Waiver
PLEASE BE ADVISED

Most of the side-effects reported while steaming are positive. Users have reported better sleep and lucid dreams, relaxation, decreased swelling in legs and feet, decreased abdominal bloating, slimmer waistline, increased libido and sexual sensation; increased vaginal nectar and fertility, decrease in breast soreness, fewer headaches, fewer PMS symptoms and improved emotional balance, increased circulation and energy, tingling feet, glowing skin, reduction in incidence of hormonal acne and increased lubrication and vaginal nectar, scar softening, tighter vaginal canal and harmonization with the moon cycle.

WHAT TO EXPECT
Steaming is a cleanse. Some of the possible signs the vaginal steaming is working is if you experience -- the urge to urinate while steaming, brown discharge after steaming, increased clots or cramps during the period, increased dry cramps, increased irregular vaginal discharge (white, green, thick, clumpy), emotional release, periods that come earlier or later than expected. All of these signs are a normal part of the cleansing process and these signs will go away once the cleanse is complete. Please note these changes and let your practitioner know of these positive changes.

BEST PRACTICES
1) Go to the bathroom directly prior to vaginal steaming.

2) Learn proper period care. Avoid tampon use and instead use cotton pads or period panties. The period is a uterine cleanse and if you support it the clots can easily clear out. Plugging up with tampons, on the other hand, prevents the old residue from clearing out and that is often the cause of cramping. It's also important to rest during the period and to eat the right foods.

3) Increased vaginal discharge can be addressed by using cotton underwear liners and a peri-bottle throughout the day to clean mucus off the skin.

4) Having a plant based diet will drastically help your life and the health of your vagina. Incorparte more fresh fruits and vegtables.

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.
****
In 99% of all cases using a mild 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.
****
Note: It is best practice to check that your vaginal steam specialist has a Vaginal Steam Facilitator certificate in good standing. This certification ensures that your practitioner knows the proper safety standards regarding setting up a vaginal steam session tailored to fit your needs.

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.

Please Print and sign your name below to confirm you understand all of the benifits steaming will provide.

***Please Note: BRING a Clean Pair of Underwear After Each Steam***
Client Name (Signature)

First NameLast Name
Signature

Clear
Date of Signature
Practitioner Use Only

Which Setup Would Be Best?

	Yes	No
Steaming is Contraindicated
Mild Session
Advanced Session
Cleansing Herbs
Gentle Herbs
Disinfecting Herbs
Cooling Herbs
Cloak
No Cloak

What Steam Schedule Do You Recommend? (Weekly or 3x Before/After the Period)
What Type of Music do You Prefer while Steaming?
Should be Empty:

Yoni Steam Intake Form