Peristeam Facilitator Intake Form by the Steamy Chick Institute

Peristeam Facilitator Intake Form

Provided by the Peristeam Hydrotherapy Institute by Steamy Chick
This intake form does not apply if someone is postpartum (0-12 months) or for pregnancy loss (if the period has not yet returned). For steam plans regarding these situations please seek a consultation with a Peristeam Hydrotherapist.
Date

MonthDayYear
Date
Client Name*

First NameLast Name
Client Email*
example@example.com
Phone Number (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Your Practitioner's Contact Details

Please enter the name and email of the practitioner who sent you this form.
Practitioner Name
Company (optional)
Practitioner Email*
example@example.com

Rows	Yes	Not Sure	No
Do you have a genital or rectal infection characterized with a burning sensation?

Rows	Yes	Not Sure	No
Are your menstrual cycles currently or historically ever 27 days or shorter?
Do you have a history of spontaneous bleeding or 2 periods per month (3 months ago or later in the past)?

Rows	Yes	No
Are you age 13 or younger?

Rows	Yes	Not Sure	No
Is this your first time doing a steam session?

Pre-Steam Advisories

What You Should Know Before Steaming
My initials below acknowledge that I was provided a copy of the Pre-Steam Advisories*

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 or unexpected occurs. Filling out this waiver is required to receive products or services from the practitioner.
Printed Signature*

First NameLast Name
If under 18 please have the parent/guardian sign above and provide the child's name below

Child's First NameChild's Last Name
Date

MonthDayYear
Date

End of Client Section

Thank you so much for all of the information. This is the end of the client intake form. Please mark the "submit to practitioner" button below to send a copy of your answers to the client email and practitioner email entered on the beginning of this intake form.
Only click below if you are the Practitioner listed at the top of this form.

Rows	Yes	Not Sure	No
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 or patch (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?
Are you within 6 weeks post-surgery?
Have you had a uterine fibroid embolization procedure?

Rows	Yes	Not Sure	No
Have you experienced any hot flashes over the past month?
Have you experienced any nightsweats over the past month?
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 active or dormant herpes?

Rows	Yes	Sometimes	No
Do you ever have menstrual cycles 27 days or less?
In the past month did you have any fresh spotting menstrual cycle day 27 or earlier?
Have you had ongoing bleeding (bleeding that lasts 10 days or longer of fresh blood) in the past 3 months?
Do you have a history of spontaneous bleeding or 2 periods per month?
Are you 12 years of age or younger?

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

Rows	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 (bad smelling) vaginal discharge?

Peristeam Facilitator Intake Form

Rows	Yes	Not Sure	No
Are you currently on your period or experiencing fresh ongoing bleeding?
Have you had fresh spotting with the past 24 hours?
Have you had spontaneous heavy bleeding within the past 3 months?
Have you had 2 periods per month (i.e a period every 19 days or less) within the past 3 months?

Rows	Yes	Not Sure	No
Are you pregnant?
Is there a possibility you are pregnant?
If receiving fertility assistance, are you past ovulation or IUI/IVF transfer?

Rows	Yes	Sometimes	No
Are your menstrual cycles 28 days or longer?
Is menstrual cycle absent or missing because of known or unknown reason? Or are you a non-menstruator (born without uterus)?
Are you currently taking birth control pills?

Rows	Yes	Sometimes	No
Do you have hot flashes?
Do you have nightsweats?
Do you radiate heat?
Are you prone to genital infections or viruses?
Is it currently hot weather?
Do you have an aversion to heat?