Vaginal Steam Consultation Form

Vaginal Steam Consultation Form
Please submit this consultation form 24-48 hours prior to booking your yoni steam session.
Client Name*

First NameLast Name
Client Email *
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Current Date

MonthDayYear
Date
Practitioner Name*
Emily Vargas
Practitioner Email*
skinandyoni@gmail.com

Client Information
Are You A Good Candidate For Vaginal Steaming?

Please review the following questions and answer them as honestly as possible, as there are certain times and/or signs where vaginal steaming is not recommended and should be avoided. Please complete the entire consultation form even if it is inadvisable to steam at this particular time. You may still be a good candidate for v-steaming in the future. We will discuss the potential possibilities by creating a tailored plan of action via phone or email to help get you started.

Please Mark any of the following Absolute Contraindications (Inadvisable to Steam at this time.) *

	Yes	No	Unsure
Are you currently on your period?
Are you currently spotting fresh blood (i.e bright red blood)?
Have you had spontaneous heavy bleeding within the past 3 months?
Have you had two periods per month (i.e. a period every 2 weeks) in the past 3 months?
Are you pregnant?
Is there a possibility that you may be pregnant?
If trying to conceive are you past ovulation or IUI/IVF transfer?
Have you had any form of surgery within the past 6 weeks (i.e. hysterectomy, cesarean, fibroid removal) ?

Please Provide further Information for Responses that are "Yes" or "Unsure"
i.e. when will your period begin and/or end, how long have you been spotting for?

Please Mark any of the following Birth Control Methods you currently use*

	Yes	No	Unsure
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)?
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?
Do you have an Essure insert? (Essure is inserted through the vagina and cervix into the fallopian tubes)

IMPORTANT

If you are using any of the above birth control methods including tubal coagulation or uterine ablation it may be possible that vaginal steaming could cause the birth control to be ineffective.

Steaming is not recommended unless you are okay with using a backup form of birth control or you are not concerned about your birth control failing.

Please Mark Yes or No if you currently have Vaginal Burning Itch*

	Yes	No	Unsure
Do you have an infection characterized with a burning itch?

Please Provide further Information for Responses that are "Yes" or "Unsure"
i.e. how long have you had this burning itch, have you been tested for possible infection?
Important

Steaming with present burning itch will only heighten the discomfort, as the steam introduces more heat. Once the burning itch subsides you may begin vaginal steaming to help prevent future infections.

We will discuss a plan of action if burning itch is present.
Steam 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 suits you. Let's see if you have any sensitivities.

Please Mark All That Apply

	Yes	Not Sure	No
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 nightsweats 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?
Are you currently or historically prone to urinary tract infections (bladder infections)?
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 (3 months or later in the past)?

Please Provide Further Information for Responses that are "Yes" or "Not Sure"
The above "yes" replies indicate steam sensitivity in which case a mild 10 min setup without an electric burner should be used. Under no circumstances should clients who have sensitivity use an advanced setup with an electric burner.
No Periods
If you don't have periods what is the reason?

HysterectomyPregnancyPostpartumPostmenopauseHaven't Had First Period YetDepo-Provera Birth Control ShotOral Birth ControlIUDI'm not sure -- they are absentOther
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 herbal steam formula for you.

	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?

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

	Yes	Sometimes	No
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?

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

Do you have any known allergies?

Heat Sensitivities

	Yes	No
Do you have hot flashes?
Do you have nightsweats?
Do you naturally run warm or get hot easily
Are you prone to vaginal infections or viruses?
Is it hot weather?
Do you have an aversion to heat?

Please Provide Further Information for Any Checked Responses
What to Expect
Steaming is a cleanse. Some of the possible signs the vaginal steaming is working is if you experience the following: urination urge while steaming, brown discharge after steaming, increased clots or cramps during the next 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 should go away once the cleanse is complete. Please note these changes and inform your practitoner.
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. For more information about proper period care please ask your practitioner.

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.
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 plan 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 most cases using a mild steam session and custom 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.
INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

Below is a legal waiver between the practitioner and the client stating that the client will not sue the practitioner in the event that something undesired occurs. Filling out this waiver is required to receive products or services from the practitioner.
Client Name *

First NameLast Name
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 I have reviewed the “Best Practices” and other information provided to me by Skin + Yoni, LLC. I further affirm, that all information provided to Skin + Yoni, LLC. 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 Skin + Yoni, LLC. to 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 the Company premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release Company, 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.

Company, 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 Company, 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 Company, 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 Company and its representatives to obtain, on my behalf, emergency medical treatment at my expense.

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.

My printed name and date below represent my signature.
Client Name (Signature)*

First NameLast Name
Date of Signature*
End of Client Section
Thank you so much for all of the information. This is the end of the client intake form. Please mark submit below to send this information to your practitioner.
Beginning of Practitioner Section

PRACTITIONER USE ONLY
The following section is for steam practitioner use only. Are you the steam practitioner?

YesNo

All done! If you would like to save a PDF version of this intake form please click "Print Form"and save a PDF file before you hit the submit button.
Should be Empty:

	Yes	No
There is a Hard Contraindication and Steam Session Should Not Be Done
There is a Soft Contraindication and Steam Session Should Be Discussed Further
Client is Safe to Steam

	Yes	No
Cleansing Herbs
Gentle Herbs
Disinfecting Herbs
Cooling Herbs

	Yes	No
Weekly
3 Days in a Row Before Period and 3 Days in a Row After Period
All of the Above
Whichever Schedule is Most Convenient for Client

	Yes	No
Mild Session - No Heat - 10 Min
Advanced Session - Heat - 30 Min

	Yes	No
Cloak - If Desired
No Cloak

Vaginal Steam Consultation Form

Client Information

Are You A Good Candidate For Vaginal Steaming?

Steam Sensitivities

No Periods

Herb Selection

What to Expect

Best Practices

Caution Signs

INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

End of Client Section

Beginning of Practitioner Section

Practitioner Section

Steam Plan