Yoni Steam Form

Vaginal Steam Intake Form

Divine Spa and Body
Name*

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example@example.com
Today's Date*

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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.

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 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?
Do you have open sores/rashes?
Do you have an infection characterized with a burning itch?
Do you have an IUD in?
Do you have a heavy cycle?

IMPORTANT

The above "Yes" replies indicate that vaginal steaming is contraindicated. It is not safe and could result in negative side effects.
Other Information:
Sensitivities

If you are in this category then it is okay to steam, however we will adjust your steam session and herbs so that it suits you.

Please Mark All That Apply*

	Yes	No	Not Sure
Is this your first time doing a steam session?
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)
Do you have a history of spontaneous bleeding or two periods per month (3 months or later in the past)?

Other Information:
Herb Selection

It is best to select herbs suitable to your constitution. We will use the info from this intake form to select a suitable vaginal steam formula for you.

Indicators for Disinfecting Herbs*

	Yes	No	Sometimes
Do you have any abnormal vaginal discharge?
Do you suffer with yeast infections?
Do you have any type of dry infection (without vaginal discharge)?

Indicators for Specialty Herbs*

If answered "no" above, a basic vaginal Detox/Cleanse herb selection is best for you.
Do You Have Any Food or Plant Allergies?*
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
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, some discharge after steaming, periods that come earlier or later than expected, are all a normal part of the cleansing process and these signs will go away once the cleanse is complete.
Best Practices
1) Go to the bathroom directly prior to vaginal steaming.

2) Increased vaginal discharge can be addressed by using cotton underwear liners
Signature

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Vaginal Steam Intake Form