STEAM SISTAHS

STEAM SISTAHS

Her
Vaginal Steam

Intake Form
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Birth Date *
Email *
example@example.com
Referred By/ How did you discover Steam Sistahs?
Emergency Contact *

Name Phone/Relationship
Contraindications

There are times when it is not beneficial for women 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?
Have you had fresh spotting in the last 48 hours?
Have you had any spontaneous bleeding within the past 3 months?
Have you had two periods per month in the last 3 months?
If trying to conceive, are you past ovulation?
Have you had laser hair removal in the last two weeks?
Have you waxed in the last five days?

IMPORTANT

The above "Yes" replies indicate the vaginal steaming is contradicted. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Streaming should not be performed at this time.
Where are you in the life stage of your cycle? *

Monthly menstrual cycle Per-Menopausal Menopausal Post Menopause Full Hysterectomy Post Partum cycle not yet returned Post Partum cycle has returned
If you are a menstruating women, when was your first day of your last menstrual cycle? *

Month Day Year
Date
Type of flow *

Light flow Medium flow Heavy flow No longer bleed
If you are a menstruating women, how long is your menstrual cycle. *
Color of blood, please select all that apply *

No longer bleed Red only Brown Black Pink and red only Clots during flow Stringy blood Brown blood at start of flow Brown blood at end of flow Shades of red and brown Bright red spotting during month Brown spotting during month Post partum not bleeding yet Other

Please answer the following questions.

Menstrual products currently being used, check all that apply.

Please Mark Any of the Following that Apply *

	Yes	No	Not Sure
Do you have an infection characterized with a burning itch?
Do you have to 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)

IMPORTANT
- if you are using the above birth-control methods vaginal steaming could cause a birth control failure. It is not recommended unless you are OK with a back up form of birth control or you are not concerned about a possible pregnancy.
- if you have a burning itch the warmth from the steam could be uncomfortable since there is already so much heat in the area. In this case it is best to seek treatment before undergoing steam treatment.
List current birth control method if any. *
Pregnancy info, please check all that apply *

I have never been pregnant I have been pregnant I am currently trying to get pregnant I am currently undergoing fertility treatments I have birth a baby vaginally I have had a cesarean section Forcep delivery Episiotomy Induction Stitches Hemorrhoids Other
How many children have you birthed?
Sensitivities

Some women are very responsive to steam and it can cause a psychological response. If you are in this category then it is OK to steam however your practitioner will adjust your steam session and herbs so that it perfectly suits you.

Please Mark Any of the Following that Apply *

	Yes	No	Not Sure
Is this your first time doing a steam session?
Do you have an IUD in?
Are you currently or historically prone to bacterial vaginosis?
Do you have herpes?
Do you have the NuvaRing in?(If so, it should be removed prior to steam session)
Do you have piercings near your vagina? (If so, please remove the steam could cause the metal to heat and burn)

If you have herpes, have you had any outbreaks in the last 72 hours?

Yes No
Are you currently or in the last three months, experienced any of the following? *

Vaginal odor Vaginal dryness Short periods (shorter than 26 days) Long periods (longer than 31 days) Hot flashes Reoccurring BV or yeast infections No concerns at the moment
Do you have any known food or plant allergies? *
Please list all that apply.
Do you have any questions or concerns before you begin your vaginal steam session. *
All the above information is accurate. *

Clear
I First Name* Last Name* understand I am having this vaginal/yoni steam bath at my own risk and hereby release STEAM SISTAHS from any liability.
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Vaginal Steam