Men's Pelvic Steam Intake Form

Men's Pelvic Steam Intake Form

Provided by PeriSteam Atlanta of Dream Wellness Solutions, Inc.
Patient Name*

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

Area CodePhone Number
What is your preferred method of communication:

EmailText messageCall
Payment Method*
If using AmeriPlan, please complete the Member ID Information below.
Insurance Provider
Humana, BC/BS Anthem, Cigna, etc.
Name of Primary Insured

First NameLast Name
Patient or Member ID
Member ID
Group Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Date

MonthDayYear
Date
Your Practitioner's Contact Details

Name and email of the practitioner who sent you this form.
Practitioner
Practitioner Email

Client Information

Do you have or have you experienced any of the following issues in the last 6 months?

	Yes	No	Frequently	Very Frequently	Rarely	Always	Never
Erectile Dysfunction
Prostate Health
Enlarged Prostate
Any Penile or Scrotal Diseases
Rectal Issues
Constipation
Does your mate have or had Bacterial vaginosis
Does your mate have or had yeast infections
Is your scrotum swollen or was it in the past (inflammation of the scrotum)
Does you mate complain about your sweaty or smelly balls?

Please Mark Any of the Following

	Yes	No
Is this your first time doing a pelvic steam?
Do you have an infection characterized with a burning itch?

Please Provide Further Information for Responses that are "Yes"
Steam Sensitivities

Some men are responsive to steam and it can cause a physiological response. If you are in this category then it is okay to steam, however your steam session and herbs will be adjusted to suits you.
If "Yes" to allergies list below
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.
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.

Indicators for a Cleansing Herb Formula

	Yes	No	Maybe
Is your mate currently or historically prone to yeast infections?
Is your mate currently or historically prone to bacterial vaginosis?

Indicators for a Gentle Herb Formula

Yes No

Do you have Herpes
If there are any "Yes" signs for the Gentle herbs this formula will always be the best choice.

	Yes	No
Do you have Herpes

Indicators for a Disinfecting Herb Formula

	Yes	No
Do you have green discharge?
Do you have yellow discharge?
Do you have thick discharge
Does your mate have malodorous vaginal discharge?
Does your mate have clear bad-smelling discharge?

Indicators for a Cooling Herb Formula

	Yes	No	Maybe
Do you urinate often?
Have you experienced pre-ejaculation within 30 days or the last few months?
Is the weather currently very hot?
Do you have an aversion to heat?
Do you radiate heat?

Do You Have Any Food or Plant Allergies?
Cloaking

When steaming it is often commonplace to wear a cloak to make the entire body sweat and thereby enhance the detoxification of the steam session. A cloak is often a blanket put over the entire body or a thick robe. Cloaking is not recommended if the body already has excess heat. Let's check to see if you have any signs of excess heat.

Mark All Excess Heat Indicators that Apply

	Yes	No
Do you radiate heat?
Is it hot weather?
Do you have an aversion to heat?

Please Provide Further Information for Any Checked Responses
Please select robe size?

Medium/LargeXL/XXL3XL
Yes answers indicate excess heat in which case cloaking is not necessary. Instead use a towel, light robe, or light wrap-around fabric.
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 pelvic steaming.

2) Learn proper penile, rectal, and prostate care.

3) Cleanse (shower) your penis and testicles regularly, especially in hot weather or athletic activity. First, use an anti-bacterial soap (i.e. dial antibacterial bar soap) to cleanse the bacteria off your entire body. Recommend: shower twice a day, follow with a shea butter-cream, Eucerin, or lotion for dry skin.
Caution Signs
If steaming causes a rash, bumps, headaches, itchiness, or diarrhea, 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 mild 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 PeriSteam Atlanta and the patient stating that the client will not sue PeriSteam Atlanta in the event that something undesired occurs. Filling out this waiver is required to receive products or services from PeriSteam Atlanta.
Client Name *

First NameLast Name
THIS AGREEMENT is made between Dr. Karen Davis, PeriSteam Atlanta 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 PeriSteam Atlanta (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 I have reviewed the “Best Practices” and other information provided to me by PeriSteam Atlanta or its agents. I further affirm, that all information provided to PeriSteam Atlanta 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 PeriSteam Atlanta 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 PeriSteam Atlanta premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release PeriSteam Atlanta, 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 affirm that I have confirmed on www.steamychick.com that PeriSteam Atlanta's practitioner has a vaginal steam specialist certification.

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.

PeriSteam Atlanta, 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 PeriSteam Atlanta, 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 PeriSteam Atlanta, 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 PeriSteam Atlanta 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 the State of California 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.

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

First NameLast Name
Date of Signature*

MonthDayYear
What two days of the week are best for a TeleHealth Consultation*
(Hold Ctrl to select options)
End of Patient 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

	Yes	No
Client is Safe to Steam

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	Yes	No
Cleansing Herbs
Gentle Herbs
Disinfecting Herbs
Cooling Herbs

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

	Yes	No
Cloak - If Desired
No Cloak

	Yes	No
Weekly
Whichever Schedule is Most Convenient for Client

Men's Pelvic Steam Intake Form

Your Practitioner's Contact Details

Client Information

Steam Sensitivities

Herb Selection

Cloaking

What to Expect

Best Practices

Caution Signs

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

End of Patient Section

Beginning of Practitioner Section

Practitioner Section

Pelvic Steam Plan