V-Steam Intake Form

Name

First Name Last Name

Email

example@example.com

Phone Number

Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Contradictions

There are times when it is not beneficial for a woman to steam. First lets check and make sure that you do not have any contradictions. A "Yes" reply to any of the questions below will indicate a contradiction. This means it is not safe and could result in negative side effects such as the onset of bleeding ot a miscarriage. Steaming should not be performed during this time.

Date

Are you currently on your period?

Have you had spontaneous bleeding in last 3 months?

Do you currently have fresh spotting?

Have you had 2 periods per month in the last 3 months?

Are you pregnant?

If trying to conceive are you past ovulation?

Please mark the following that Apply...

YES

NO

Do you have an infection with a burning itch?

Do you have tubal coagulation (burning of fallopian tubes)?

Do you have a birth control arm implant?

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 with 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 practioner will adjust your steam session and herbs so that it perfectly fits you.

Please Mark Any of the Following that Apply

YES

NO

Is this your first time doing a steam session?

Are your mensural cycles currently 27 days or less?

Do you experience hot flashes?

Do you have night sweats?

Do you have an IUD?

Are you prone to yeast infections?

Are you prone to bacterial vaginosis?

Do you have herpes?

Do you have a Nuva Ring in?

Are you under 18 years old?

The above "YES" replies indicate sensitiviy in which cause a mild setup which should be performed 10-15 minutes. Under no circumstances should clients who have sensitivity use an advanced setup which is 30-45 minute steam sessions.

Do you have any Food or Plant Allergies?

Do you have any questions or hesitations prior to your Steam Session?