SunSoul Steams Intake Form

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Client Name

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Practitioner Name: Kaylee Lambert, Founder of SunSoulistic

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Client Email

example@example.com

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Practitioner Email: info@sunsoulistic.com

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Phone Number

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AddressThis will only be used if/when steams are curated for me to send you directly.

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What is your reason for doing a steam session

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Preferred Gender Pronouns

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What are your reproductive organs

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Has your genitalia anatomy altered at all since birth due to sex change alterations

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Uterine Bleeding Contraindications

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Are you currently on your period or experiencing fresh ongoing bleedingYES/NO/NOT SURE

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Have you had fresh spotting within the past 24 hoursYES/NO/NOT SURE

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Have you had 2 periods per month (i.e. a period every 19 days or less) within the past3 monthsYES/NO/NOT SURE

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Pregnancy Contraindications

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Are you pregnantYES/NO

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Is there a possibility you are pregnantYES/NO

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If receiving fertility assistance, are you past ovulation or IUI/IVF transferYES/NO

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Medical Contraindications

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Do you have tubal coagulation burning of the fallopian tubes through laparoscopic surgery through the bellybuttonYES/NO/NOT SURE

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Have you had a uterine ablation procedure where the uterine walls are burned so they scar overYES/NO/NOT SURE

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Do you have a birth control arm implant or patch (ie nexplanon)YES/NO/NOT SURE

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Do you have an Essure insertYES/NO/NOT SURE

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Are you within 6 weeks post-surgeryYES/NO

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Have you had a uterine fibroid embolization procedureYES/NO

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Heat Contraindications

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Do you have a genital or rectal infection characterized with a burning sensationYES/NO *any further information

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Uterine Bleeding Sensitivity

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Are your menstrual cycles currently or historically every 27 days or shorterYES/NO/NOT SURE

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Do you have a history of spontaneous bleeding or 2 periods per month (3 months ago or later in the past)YES/NO/NOT SURE

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Heat Sensitivity

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Have you experienced any hot flashes over the past monthYES/NO/NOT SURE

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Have you experienced any night sweats over the past monthYES/NO/NOT SURE

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Are you currently or historically prone to yeast infectionsYES/NO/NOT SURE

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Are you currently or historically prone to bacterial vaginosis YES/NO/NOT SURE

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Are you currently or historically prone to urinary tract infections (bladder infections)YES/NO/NOT SURE

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Do you have active or dormant herpesYES/NO/NOT SURE

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Medical Sensitivity

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Do you have an IUDYES/NO

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Do you have a nuva ring inYES/NO

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Age Sensitivity

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Are you age 13 or youngerYES/NO

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First Timer

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Is this your first time doing a steam sessionYES/NO

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Further Information

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No Period

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If you dont have periods what is the reason

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Excess Heat Indicators

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Do you have hot flashesYES/NO/SOMETIMES

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Do you have night sweatsYES/NO/SOMETIMES

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Do you radiate heatYES/NO/SOMETIMES

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Are you prone to genital infections or virusesYES/NO/SOMETIMES

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Is it currently hot weatherYES/NO/SOMETIMES

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Do you have an aversion to heatYES/NO/SOMETIMES

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Indicators for a Hemostatic Herb Formula

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Do you have menstrual cycles 27 days or lessYES/NO/SOMETIMES

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In the past month did you have any fresh spotting menstrual cycle day 27 or earlierYES/NO/SOMETIMES

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Have you had ongoing bleeding (bleeding that lasts 10 days or longer of fresh blood) in the past 3 monthsYES/NO/SOMETIMES

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Do you have a history of spontaneous bleeding or 2 periods per monthYES/NO/SOMETIMES

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Are you 12 years of age or youngerYES/NO/SOMETIMES

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Indicators for a Cooling Herb Formula

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Do you have vaginal drynessYES/NO/SOMETIMES

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Have you experienced hot flashes recentlyYES/NO/SOMETIMES

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Have you experienced night sweats recentlyYES/NO/SOMETIMES

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Is the weather currently very hotYES/NO

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Do you have any type of dry genital infection (without discharge)YES/NO/SOMETIMES

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Do you have an aversion to heatYES/NO/SOMETIMES

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Do you radiate heatYES/NO/SOMETIMES

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Indicators for a Disinfecting Herb Formula

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Do you have green vaginal dischargeYES/NO/SOMETIMES

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Do you have yellow vaginal dischargeYES/NO/SOMETIMES

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Do you have white vaginal dischargeYES/NO/SOMETIMES

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Do you have thick vaginal dischargeYES/NO/SOMETIMES

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Do you have malodorous (bad smelling) vaginal dischargeYES/NO/SOMETIMES

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Indicators for a Cleansing Herb Formula

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Are your menstrual cycles 28 days or longerYES/NO/SOMETIMES

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Is menstrual cycle absenter missing because of known or unknown reason? Or are you a Non menstruator (born without uterus)YES/NO/SOMETIMES

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Are you currently taking birth control pills

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Plant or Food Allergies