Yoni Steam client intake form

Yoni Steam Client Intake Form
Today's Date*

MonthDayYear
Client Name

First NameLast Name
Date of Birth*

MonthDayYear
Client Email*
Client Information
Which of the following is a reproductive organ you were born with?

VaginaUterusVuvlaClitorisPenisScrotumProstateNone of the Above
Has your genitalia anatomy altered at all since birth due to voluntary or medical surgery or alterations?
Preferred Gender Pronouns?
Hard 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 don't have any contraindications.

Uterine Bleeding Contraindications

	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 19 days or less) in the past 3 months?

Pregnancy Contraindications

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

Further Information
Soft Contraindications

Medical Contraindications

	Yes	No	Not Sure
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 burnt 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?

Heat Contraindications

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

Further Information
Steam Sensitivities

Some people 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 steam session and herbs need to be adjusted so that it perfectly suits you. Let's see if you have any sensitivities.

Uterine Bleeding Sensitivity

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

Medical Sensitivity

	Yes	No	Not sure
Do you have an IUD?
Do you have a Nuva Ring in?

Heat Sensitivity

	Yes	No	Not sure
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 track infections (bladder infections)?
Do you have active or dormant herpes?

Age Sensitivity

	Yes	No	Not sure
Are you age 13 or younger?

First Timer

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

No Periods
If you don't have periods what is the reason?

HysterectomyPregnancyPostpartumPostmenopauseHaven't had first period yetBirth ControlIUDI'm not sure, They are absentI am a Non-Menstruator (born without a uterus)Other
Please provide further 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 herbal steam formula for you.

Indicators for a Hemostatic Herb Formula

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

Indicators for a Cooling Herb Formula

	Yes	No
Do you have vaginal dryness?
Have you experienced hot flashes recently?
Have you experienced night sweats 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?

Indicators for a Disinfecting Herb Formula

	Yes	No	Sometimes
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?

Indicators for a Cleansing Herb Formula

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

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	Somtimes
Do you have hot flashes?
Do you have night sweats?
Do you radiate heat?
Are you prone to infections or viruses?
Is it hot weather?
Do you have an aversion to heat?

Do You Have Any Questions or Hesitations Prior to Your Vaginal Steam Session?
What is your experience with pelvic steaming? (Please indicate if you have ever done it before. If so, please describe your experience, period changes, herbs and set up used, and any questions or complications)
Steaming is very effective at overhauling the reproductive health system when done weekly for three to six months or until all issues resolve. Menstruators will want to do a new intake form with their Peristeam Facilitator after every menstrual cycle to see if herbs or the setup need adjustment which commonly is the case. Which of the following would you be interested in?

Monthly steam intakeOne time steam intake without continued monthly intake

Informed Consent, Waiver, Release of Liability

[RADIANT WOMBEN] INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM
[RADIANT WOMBEN] INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM THIS AGREEMENT is made between _______________________________ (“Company”) and ___________________________ ("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 governing body that the practitioner resides in and any dispute under this Agreement must be brought to a court in this locality 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.

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First NameLast Name
Date of Signature
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Yoni Steam Client Intake Form

Client Information

Hard Contraindications

Soft Contraindications

Steam Sensitivities

No Periods

Herb Selection

Cloaking

Informed Consent, Waiver, Release of Liability