Vaginal Steam Intake Form

Vaginal Steam Facilitator Intake Form

Taylor Simone at Healing Peace Steaming
VSF Intake Form - 6/16/21 Revision
We respect your privacy

This form or any of its contents will not be shared with anyone other than the Peristeam facilitator and the client unless specifically granted permission by said client, except in the case of a medical or legal emergency.
Name*

First NameLast Name
Email*
client email
Area Code
Phone Number
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Contraindications

There are times when it is not beneficial for someone to steam. As a first step, let's check and make sure that you are safe for a steam session.

Please Mark any of the following Hard Contraindications that apply*

	Yes	Not sure	No
Are you currently on your period?
Do you currently have fresh (Red or pink) 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?
Is there a possibility you are pregnant?
If trying to conceive are you past ovulation or IUI/IVF transfer?
Have you had any surgery in the past six weeks for any reason?

Please provide further information for responses that are "yes" or "not sure"
IMPORTANT
Any above "Yes" replies indicate that vaginal steaming is contraindicated. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not be performed at this time. You may still fill out the form to let the practitioner know all of your details for a future time when steaming would be safe for you.

Please mark any Soft Contradictions that may apply:*

	Yes	Not Sure	No
Do you have an infection characterized with a burning itch?
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)?
Are there any medical or medicinal reasons why you are prohibited from physical exercise, or from the effects of warm water like a bath or hot tub?

Please provide further information for responses that are "Yes" or "Not Sure"
IMPORTANT

for "Yes or "Not sure" answers in the above table
If you are using the above long-term or "permanent" birth control methods it may be possible that vaginal steaming could cause a birth control failure. 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.

If you have a burning itch the warmth from the steam could be uncomfortable since there is already so much heat in your body. Once the burning itch subsides you may proceed with a vaginal steam.

If you have had a uterine ablation procedure (to scar over the uterine walls) it may be possible that vaginal steaming will clear the scar tissue which would reverse the surgery. If you are okay with reversing the surgery then feel free to proceed with a vaginal steam.
Sensitivities

To provide optimum comfort while steaming
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 any Sensitivities that apply to you:*

	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 night sweats over the past month?
Have you ever had a yeast infection?
Have you had bacterial vaginosis?
Have you ever had a urinary tract infection (bladder infection)?
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)?
Do you currently have an IUD?

Please Provide Further Information for Responses that are "Yes" or "Not Sure"
The above "yes" replies indicate steam sensitivity in which case a mild no heater 10 min setup without an electric burner should be used. Under no circumstances should clients who have sensitivity use an advanced heater setup with an electric burner.
Periods

Your most recent cycle is the best indicator of your steaming needs
Do you have a period?*

Yes, every monthYes, sporadicallyYes, but not for the past 3-6 monthsNot for the past 6+ months
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 absentNot applicableOther
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 Hemostatic (Gentle) herb formula*

	Yes	Sometimes	Not sure	No
Do you ever have menstrual cycles 27 days or less?
Do you have fresh (red or pink) spotting between periods?
Are you currently under the age of 13?

Please provide additional information for any "Not sure" answers here
If there are any "Yes" signs for the hemostatic (gentle) herbs this formula will always be the best!

Indicators for a Cooling herb formula*

	Yes	Sometimes	Not sure	No
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?

Please provide additional information for any "Not sure" answers here

Indicators for a Disinfecting herb formula*

	Yes	Sometimes	Not sure	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?

Please provide additional information for any "Not sure" answers here

Indicators for a Cleansing Herb Formula*

	Yes	Sometimes	Not Sure	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?
Do you frequently have brown or black blood during your period?

Please provide additional information for any "Not sure" answers here
Do You Have Any Food or Plant Allergies?
Please list them here
Cloaking

covering the body with a warm blanket while steaming is optional
After a person's first time steaming, it can be common to wear a cloak while steaming 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 optional and is not recommended if the body already has excess heat. Let's check to see if you have any signs of excess heat.

Mark any indicators of heat sensitivity that apply:*

	Yes	Not sure	No
Are you prone to vaginal infections or viruses?
Do you have an aversion to heat?
Do you radiate heat?

Please provide additional information about heat sensitivity if necessary:
Yes answers indicate excess heat in which case cloaking is not recommended. Instead use a towel, light robe, steam gown, summer dress or light wrap-around fabric.
What to Expect
Steaming is a cleanse. Some of the possible signs that vaginal steaming is working for you 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 Practice
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 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 no heater 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.
Consultation
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.
Name*

First NameLast Name
THIS AGREEMENT is made between Taylor Williams and Healing Peace Co. (as indicated in the practitioner section), The Tailored-Way Solutions LLC and Healing Peace Co (together "Company") 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 Company (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 Company or its agents. I further affirm, that all information provided to Company 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 Company 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 affirm that I have confirmed on www.steamychick.com that Company'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.

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.

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 Texas and any dispute under this Agreement must be brought in this

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.
Name*

First NameLast Name
Date of Signature*

MonthDayYear
Date
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.
End of Client Section
Beginning of Practitioner Section
PRACTITIONER USE ONLY
The following section is for steam practitioner use only. Are you the steam practitioner?

YesNo
PRACTITIONER USE ONLY
Name

First NameLast Name
Practitioner Company

Is there a contraindication to steaming? (Please refer to the intake form on contraindications)

	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

If they had a soft contraindication, did the client decide to steam or not? Why?
Which Category of Steam Herbs Would Be Best? (Please refer to the intake form section on herb selection. Yes replies indicate those herbs would be suitable. If there is more than one herb choice and "Hemostatic (gentle)" is an option, prioritize this category. If more than one option and Hemostatic (gentle) is not one of the choices choose the blend that you feel is the best choice

Hemostatic (Gentle) herbsCooling herbsDisinfecting herbsCleansing herbs
Which Steam Schedule is recommended?

Once a week3 Days in a Row Before Period and 3 Days in a Row After PeriodOther
Is Cloaking Recommended? (Please refer to intake form section on cloaking. Yes replies indicate the client should not cloak)

YesNoOther
Which Steam Setup and Duration Would Be Best? (Please refer to the intake form section on sensitivities. Yes replies indicate a mild no heater session)

Mild Setup - 10 min - no heaterAdvanced Setup -30 min - with heater
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:

Vaginal Steam Facilitator Intake Form

We respect your privacy

Contraindications

IMPORTANT

IMPORTANT

Sensitivities

Periods

Herb Selection

Cloaking

What to Expect

Best Practice

Caution Signs

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

End of Client Section

Beginning of Practitioner Section

PRACTITIONER USE ONLY

PRACTITIONER USE ONLY