Yoni Steam and Ionic Foot Detox Intake Form/Questionnaire

This Form must be completed prior to your first Yoni Steam and/or Foot Detox with LuxCherie Stuff only. It does not need to be completed for any subsequent sessions.

IF YOU ARE NOT GETTING A YONI STEAM, PLEASE ONLY COMPLETE SECTIONS A, C and D.

IF YOU ARE NOT GETTING A FOOT DETOX, PLEASE ONLY COMPLETE SECTIONS A, B and D.

The purpose of the information requested in this form—aside from contact information--is to assist with assessing whether a Yoni Steam and/or Foot Detox may or may not be ideal for you at this time; and—in the event that it is—to assist with determining the best session length, herb mixture, and herb concentration for your steam.

The contact information provided will be used for your Client File; and will also be added to our Contact List so we may share information with you regarding future Sales/Discounts, Products/Services, Special Events, etc.

All information provided will be kept confidential; and will be used only for the purposes stated above.

If you prefer NOT to be added to our Contact List, please enter your initials below.

Initials*

SECTION A

Full Name

First NameLast Name

E-mail Address

example@example.com

Contact Number

Address

Street Address

Street Address Line 2

CityState

Post Code

Date of Birth

DayMonthYear

SECTION B

Are you currently on your cycle?

YesNo

Are you currently spotting?

YesNo

Have you experienced any spontaneous spotting in the past 3 months?

YesNo

Have you had more than one cycle within a 30-day period in the past 3 months?

YesNo

Are you currently pregnant?

YesNo

Are you currently experiencing any itching and/or burning sensation in your vaginal area?

YesNo

If you have answered Yes to any of the above questions, vaginal steaming may not be ideal for you at this time as it may result in unwanted effect(s) such as—but not limited to--heavier cycle; onset of cycle; further irritation; or miscarriage.

If you are currently using an arm implant for birth control, it is recommended that you use a backup form of birth control for at least 2 weeks following your Yoni Steam as steaming could weaken the effects of the birth control.

If you do not have a menstrual cycle at all, please provide a brief reason why. If this does not apply to you, please type “N/A”.

Are you currently taking any regular medication(s), including birth control?

YesNo

If "Yes", please list medication(s) below; otherwise, please type "N/A".

How long ago was you last menstrual cycle?

When do you expect your next menstrual cycle to begin?

How many days does your menstrual cycle usually last?

How often do you get your cycle (ex: Every 30 days; Every 45 days; Every other month)?

Do you have irregular menstrual cycles?

YesNo

Do you experience vaginal dryness regularly?

YesNo

Do you have any concerns regarding fertility?

YesNo

How long ago was your last pregnancy? If never pregnant, please write “N/A”.

Have you given birth, had an abortion, or miscarried in the past 3 months?

YesNo

Some may be more sensitive to Yoni Steaming than others. The purpose of the following questions is to assist with determining the most ideal session length and herb concentration for your Steam.

Are you under 18 years of age?

YesNo

Are you a virgin?

YesNo

Will this be your first time steaming?

YesNo

Do you currently have more than one cycle within a 30-day period?

YesNo

Do you experience hot flashes?

YesNo

Do you have night sweats?

YesNo

Do you currently have an IUD?

YesNo

Are you currently using the Nuva Ring?

YesNo

Are you prone to yeast infections?

YesNo

Are you prone to bacterial vaginosis?

YesNo

Have you been diagnosed with genital herpes and/or warts?

YesNo

If you have answered “Yes” to any of the above questions, the length of your steam session and/or the amount of herbs used for your steam may be adjusted from the standard length and/or concentration.

SECTION C

It is recommended that you DO NOT use Ionic Foot Detox without prior medical approval or real time medical supervision under the following circumstances:

- If you’re pregnant or nursing.

- If you have a pacemaker, or other electronic implement.

- If you’ve had an organ transplant.

- If you have epilepsy.

- If you have any open wound(s) on your feet and/or ankles.

- If currently undergoing any form of radiation or chemotherapy.

- If you suffer from psychotic episodes.

- If you suffer from seizures.

- If you have advanced stage diabetes.

- If you are a hemophiliac or taking blood thinners.

Do any of the above circumstances apply to you?

YesNo

If you’ve answered Yes, LuxCherie Stuff requires that you present a note of approval issued by your medical doctor prior to receiving this service.

SECTION D

Do you have any known food and/or plant allergies?

YesNo

If you answered Yes to the above, please list the item(s) you are allergic to below.

Please list any questions/concerns that you have below.