VSF Intake Form

Vaginal Steam Facilitator Intake Form

Provided by the Peristeam Hydrotherapy Institute
Practitioner Name *

First Name Last Name
Practitioner Email *
example@example.com
Client Name *

First Name Last Name
Client Email *
example@example.com
Today's Date

Month Day Year
Date
Contraindications

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.

Please Mark Any of the Following that Apply

	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 2 weeks) in the past 3 months?
Are you pregnant?
If trying to conceive are you past ovulation or IUI/IVF transfer?

IMPORTANT

The above "Yes" replies indicate that vaginal steaming is contraindicated. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not be performed at this time.

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 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)?
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?
Do you have an Essure insert?

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 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. You could also try doing a sitz bath with cooling herbs.

If you have had a uterine ablation procedure (to scar over the uterine walls) it is possible that vaginal steaming will clear the scar tissue reversing the surgery.
Notes
Sensitivities

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 suits you.

Please Mark All That Apply

	Yes	No	Not Sure
Is this your first time doing a steam session?
Are your menstrual cycles currently or historically ever 27 days or shorter?
Have you experienced any hot flashes over the past month?
Have you experienced any nightsweats over the past month?
Do you have an IUD in?
Are you currently or historically prone to yeast infections?
Are you currently or historically prone to bacterial vaginosis?
Do you have herpes?
Do you have the nuva ring in? (If so, it should be removed prior to steam session)
Are you age 13 or younger?
Do you have a history of spontaneous bleeding or two periods per month (3 months or later in the past)?

Notes
The above "yes" replies indicate sensitivity in which case a mild setup without a burner should be used. Under no circumstances should clients who have sensitivity use an advanced setup with a burner.
Herb Selection

It is best to select herbs suitable to your constitution. Your practitioner will use the info from this intake form to select a suitable vaginal steam formula for you.

Indicators for Cleansing Herbs

	Yes	No
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?

Indicators for Gentle Herbs

	Yes	No
Do you ever have menstrual cycles 27 days or less?
Do you have fresh spotting between periods?
Are you currently underage 13?

If there are any "Yes" signs for the Gentle herbs this formula will always be the best choice.

Indicators for Disinfecting Herbs

	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?

Notes

Indicators for Cooling Herbs

	Yes	No
Do you have vaginal dryness?
Have you experienced hot flashes recently?
Have you experienced nightsweats recently
Do you have any type of dry infection (without vaginal discharge)?
Is the weather currently very hot?
Do you have an aversion to heat?
Do you radiate heat?

Do You Have Any Food or Plant Allergies?
Cloaking

When steaming it is often commonplace to wear a cloak or steam gown. Cloaking helps to increase the benefit of the treatment by enhancing the detoxification of the session. A couple notes of caution -first, it is not advised to use plastic as a cloak as it may release toxins when heated. Second, cloaking is not a good idea if you already have excess heat in your body. Let's check to see if you have any signs of excess heat.

Mark All Excess Heat Indicators that Apply

	Yes	No
Do you have hot flashes?
Do you have nightsweats?
Do you radiate heat?
Are you prone to infections or viruses?
Is it hot weather?
Do you have an aversion to heat?

Notes
Yes answers indicate excess heat in which case cloaking is not necessary. Instead use a towel, light robe, steam gown, summer dress or light wrap-around fabric.
No Periods
If you don't have periods what is the reason?

Hysterectomy Pregnancy Postpartum Postmenopause Haven't Had First Period Yet Depo-Provera Birth Control Shot Oral Birth Control IUD I'm not sure -- they are absent Other
Notes
What to Expect
Steaming is a cleanse. Some of the possible signs the vaginal steaming is working is if you experience -- the urge to urinate while steaming, brown discharge after steaming, increased clots or cramps during the period, increased dry cramps, increased irregular vaginal discharge (white, green, thick, clumpy), emotional release, periods that come earlier or later than expected. All of these signs are a normal part of the cleansing process and these signs will go away once the cleanse is complete. Please note these changes and inform your practitoner.
Best Practices
1) Go to the bathroom directly prior to vaginal steaming.

2) Learn proper period care. Avoid tampon use and instead use cotton pads or period panties. The period is a uterine cleanse and if you support it the clots can easily clear out. Plugging up with tampons, on the other hand, prevents the old residue from clearing out and that is often the cause of cramping. It's also important to rest during the period and to eat the right foods. For more information about proper period care please take the course -- Womb Cleanse Care -- available on the Steamy Chick website.

3) Increased vaginal discharge can be addressed by using cotton underwear liners and a peri-bottle throughout the day to clean mucus off the skin.
Caution Signs
If steaming causes a rash, bumps, headaches, itchiness, diarrhea or the onset of fresh spotting or inter-period bleeding, this could be a sign that your steam plan or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur please let your practitioner know so they can adjust the steam session as necessary or make a referral.
****
In most cases using a mild steam session and mild herbs will prevent any of the above signs from happening so it's very important that you give honest answers in this intake form so that the practitioner can set up a steam session that will fit your needs.
INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

Below is a legal waiver between the practitioner and the client stating that the client will not sue the practitioner in the event that something undesired occurs. Filling out this waiver is required to receive products or services from the practitioner.
Practitioner Name *

First Name Last Name
Practitioner Company Name (if any)
Client Name *

First Name Last Name
THIS AGREEMENT is made between Practitioner Name and Company (as typed in the field above) (“Company”) and Client (as typed in the field above) ("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 State of California and any dispute under this Agreement must be brought in this venue 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.

My printed name and date below represent my signature.
Client Name (Signature) *

First Name Last Name
Date of Signature *
Practitioner Use Only

Which Setup Would Be Best?

	Yes	No
Steaming is Contraindicated
Mild Session
Advanced Session
Cleansing Herbs
Gentle Herbs
Disinfecting Herbs
Cooling Herbs
Cloak
No Cloak

What Steam Schedule Do You Recommend? (Weekly or 3x Before/After the Period)
Should be Empty:

Vaginal Steam Facilitator Intake Form

Contraindications

Sensitivities

Herb Selection

Cloaking

No Periods

What to Expect

Best Practices

Caution Signs

INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM