YONI STEAM HYDROTHERAPY INTAKE & CONSENT FORM

2000 Metropica way Sunrise Blvd, Sunrise, FL 33323

Name

DATE OF BIRTH

Address

City

State

Zip

Phone Number

Email Address

example@example.com

There are times when it is not beneficial for a woman to steam. First, let's check and make sure that you don't have any contraindications.

WHEN YONI STEAMS SHOULD BE AVOIDED:

If you are pregnant or there is a possibility of pregnancy During menstruation With any open wounds, sores, blisters or stitches Piercings will need to be removed Infection with burning Caution: If you have an IUD, Yoni steams help release matter from the uterus. They are on the caution list but по longer contraindicated. However, I will ask that if you have an IUD, you sign a release form that you are aware of the possibility of your IUD releasing.

During or after ovulation if you are trying to conceive
Fresh spotting or spontaneous bleeding
If you have a vaginal infection or fever Birth control implant (Nexplanon, Implanon) Tubal Coagulation

YONI STEAM HYDROTHERAPY INTAKE & CONSENT FORM

When was the first day of your last period

How often do your periods come

How long do they last

Do you have any concerns about your menstrual cycle?

How old where you when you started your period

Are you under treatment for Infertility

treatment IVF IUI etc

PLEASE ANSWER ANY OF THE FOLLOWING THAT APPLY

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)?

Are you pregnant or trying to conceive

How many pregnancies have you had in the past?

IMPORTANT: If you are using the above birth control methods vaginal steaming could cause the birth control to temporary not work. It is not recommended unless you are okay with a backup 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 that area. In this case it is best to seek treatment from an acupuncturist to get the burning sensation to go away prior to doing a vaginal steam session.

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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 perfectly suits you.

PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY

Is this your first time doing a steam session?

Are your menstrual cycles currently or historically every 27 days or Have you experienced any hot flashes over the past month?

Do you have an IUD in?

Do you have herpes?

Are you currently or historically prone to yeast infections?

Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)

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Your practitioner will use the info from this intake form to select a suitable vaginal steam formula for you.

INDICATORS FOR RESTORE/CLEANSING HERBS

INDICATORS FOR ALIGN/GENTLE HERBS

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 ever have menstrual cycles 27 days or LESS?

Do you have fresh spotting between periods?

Are you above the age of 18?

Do you currently have any form of discharge? For an example: green, yellow or white vaginal discharge, thick vaginal discharge? Do you have malodorous vaginal discharge? do describe. if not say no.

Are you experiencing vaginal dryness?

Have you experienced hot flashes recently? Have you experienced night sweats recently?

Do you have any type of dry infection (without vaginal discharge)?

Do you have any food or plant allergies

Do you have any questions or hesitations prior to your vaginal steam session

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YONI STEAM HYDROTHERAPY INTAKE & CONSENT FORM

Please read and check each statement to show your understanding and agreement. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner so that the temperature may be adjusted to my level of comfort I further understand that yoni steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a medical provider, or other qualified medical specialist for any physical or mental ailment of which I am aware.

I understand that the practitioner facilitating the yoni steam bath is not qualified to diagnose prescribe andor treat any physical or mental illness and that nothing said in the course of any session given should be construed as such.

I affirm that I have stated all of my known health conditions and answered all questions accurately completely and honestly

I agree to keep the practitioner updated as to any changes in my health profile and understand that there shall be no liability on the practitioners part should I forget to do so

Date

I understand that I am having this yoni steam at my own risk and hereby release PowerVsteam and any employee from any liability

I am aware and I understand there is a possibility that my IUD can be released due to a Yoni Steam Bath This has been explained to me and I am to proceeding with the Yoni Steam Bath at my own risk

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY

UNDERSTAND THIS AGREEMENT AND ALL THE INFORMATION DETAILED ABOVE

Name

Signature

Date

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YONI STEAM HYDROTHERAPY INTAKE & CONSENT FORM

PERSONAL INFORMATION

CONTRAINDICATIONS

YONI STEAM HYDROTHERAPY INTAKE & CONSENT FORM