Healing Yoni Steam Intake

Healing Yoni Steam Intake

New Client Questionnaire
Welcome to Art of Roots Yoni Steam Intake! It's time to get personal. Your highly detailed answers are paramount to helping us curate the most accurate steaming protocol for you, so we suggest alloting time and space to put your thorough thought into this.

At the end of each topic we have a note section for you to elaborate on anything that comes to mind along the way that you feel is relevant for us to know. There is no such thing as over-explaining, and redundancy is welcomed.

Please triple check that the email you provide us is accurate, this is our only way of contacting you and getting your protocol in hand.

Your answers are completely confidential.
The Basics
Name*

First NameLast Name
Date of birth*

MonthDayYear
What email should we contact you at?*
example@example.com
Please re-enter email to ensure accuracy:*
example@example.com
Mailing Address (mail your herbs?)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Your phone number is for backup in case we have a technical glitch reaching you through your given email. We will not contact you by phone at any other point.
How did you find Bodhi Wellness Yoni Steam?

Final Thoughts
Please share anything related to your wellbeing that you would like us to know that we haven't already asked about. Elaborate in as much detail as possible.
Questions or concerns? Please list any and all questions you have for us and we will answer it within your protocol.
Q.

What if I think of something later that I want to add in or ask?

A.

No worries! You can email us at hello@artofroots.com within 3 days of submission and we will add it to your intake in time to adjust your protocol.

INFORMRED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM
Client Name*

First NameLast Name
THIS AGREEMENT is made between Art Of Roots: One & Yoni Steam and Client (as typed in the field above) ("I") (collectively the “Parties”).

I have purchased or am receiving complimentary steaming services, products or a consultation from Art Of Roots (the "Products and/or Services").

I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in, or cause me to have an adverse reaction to, the Services, including but not limited to preterm pregnancy. I affirm that all information provided to Art Of Roots by me is accurate and complete and I understand that failing to provide information may result in a greater risk of injury. I acknowledge that my purchase and participation in or use of the Products and/or Services is voluntary and I do so entirely at my own risk. I acknowledge that I have approval from my doctor or medical professional to use or receive the Products and/or Services or I yield that requirement and take responsibility for my own medical decision-making.

I understand that results may vary from person to person. I understand that I may react adversely to the Products and/or Services and they may result in injury to me. Side effects include, but are not limited to, rash, bumps, headaches, itchiness, diarrhea, increased vaginal discharge, cramping or the onset of fresh spotting or inter-period bleeding. If I elect to continue Products and/or Services after such results, I will alert Art Of Roots: One & Yoni Steam to the issues so that the Products and/or Services may be adjusted, or a referral can be made. I expressly agree that all risk of injury that I undertake as a part of the Products and/or Services is undertaken at my sole risk.

I further expressly agree that I will not use any equipment related to the Products and/or Services improperly. If equipment is located on Art Of Root: One & Yoni Steam's premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release Art Of Roots, its agents, and employees from any claim, demands, injuries, damages, actions, or causes of action, that could occur from my inappropriate use of such equipment.

I also understand and agree that all information provided before, during, or after the Products and/or Services is for informational purposes only and is not a replacement for medical advice from a physician or pediatrician. The Products and/or Services and information provided therein does not replace the relationship between physician/therapist and a client in a one-on-one treatment session with an individualized treatment plan based on their professional evaluation. The Products and/or Services and any information therein are provided "as is" without any representations or warranties, express or implied.

I will not rely on the Products and/or Services as an alternative to advice from my medical professional or healthcare provider and I will never delay seeking medical advice, disregard medical advice, or discontinue medical treatment as a result of any information provided before, during, or after the Products and/or Services. I understand and agree that all medical related information is for informational purposes only.

Art Of Roots, its agents, and employees, shall not be liable to me for any claims, demands, injuries, damages, actions or causes of action to my person or property arising out of or connected with the Products and/or Services and the premises where the Products and/or Services are located. I expressly release Art Of Roots, its agents, and employees from all such claims, demands, injuries, damages, actions, or causes of action, and from all acts of active or passive negligence on the part of Art Of Roots, to the extent such a release of negligence is permissible by law.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during the Products and/or Services. In the event of sickness, accident, or injury, I authorize Art Of Roots and its representatives to obtain, on my behalf, emergency medical treatment at my expense.

This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. This Agreement shall be construed and enforced according to the laws of Alberta Canada and any dispute under this Agreement must be brought in this venue and no other.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I UNDERSTAND AND AGREE THAT I AM GIVING UP LEGAL RIGHTS BY SIGNING THIS AGREEMENT AND THAT I AM DOING SO VOLUNTARILY, FREELY, UNDER NO THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE, OR GUARANTEE BEING COMMUNICATED TO ME. THE SIGNATURE BELOW IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW.
Client Signature*

Clear
Today's Date*

MonthDayYear

Submit Questionnare
Should be Empty:

	YES	UNSURE	NO
Are you actively trying to conceive?
If so, are you using an IUI/ IVF transfer?
Are you currently pregnant?
Are you currently postpartum (9 months or less)

	YES	UNSURE	NO
Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery)?
Have you had a uterine ablation procedure?
Have you had a hysterectomy? (If so please explain below the degree of removal)
Have you had laparoscopy of the uterus for any reason?
Have you had a c-section for any reason?

	YES	SOMEWHAT	UNSURE	NO
Did you have any cramping?
Did you have any clots?
Did you have PMS before this period?
Did you have sore breasts?

	YES	UNSURE	NO or N/A
Have you had two periods per month (i.e. a period every two weeks) in the past 3 months?
Have you had spontaneous bleeding, separate from your period, in the past 3 months?
Do you ever have spotting throughout your cycle?
Do you ever have spotting around ovulation?
Do you ever have spotting approaching your period?
Do you ever have spotting following your period?
Do you ever experience brown blood or brown spotting?

	ALWAYS	SOMETIMES	NEVER or N/A
Do you use tampons?
Do you use a menstrual cup or disc?
Do you use pads?
Do you use period underwear?

	COMPLETELY	SOMEWHAT	NO or N/A
Do you prioritize full-body rest on your period?
Do you avoid over-the-counter pain relievers during your period?
Do you prioritize the consumption of warm foods and drinks during your period?
Do you avoid any insertion into the vagina, including sex and tampon use during your period?
Do you avoid exercise, exertion, and inversions during your period?
Do you prioritize adequate hydration and nutrition during your period?
Do you avoid alcohol and caffeine on your period?

	FOLLICULAR	OVULATORY	LUTEAL	MENSTRUAL	NONE
Low back pain
Moderate cramps
Severe cramps
Painful sex
Cramping during or after sex

	YES	SOMETIMES	NEVER
Do you have an aversion to heat?
Do you radiate heat?
Do you have night sweats?
Do you experience hot flashes?

	YES	UNSURE	NO
Do you currently have an infection characterized by a burning itch?
Do you currently have an infection or virus?
Are you prone to bacterial vaginosis (within the last few years)?
Are you prone to yeast infections (within the last few years)?
Are you prone to any other infections or viruses?
Do you have any type of dry infection (without discharge)?
Do you have vaginal dryness?
Do you have genital herpes?