Sultana Steam® Peristeam Hydrotherapy Intake & Screening Form
*Please note ALL submissions are kept CONFIDENTIAL and are solely used for determining the proper Steam Protocol. Please allow 72 hours for processing. Results will be emailed.
Todays Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Date of Birth
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Month
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Day
Year
Date
Height
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Weight
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Emergency Contact
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Referred By
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Will this be your first time receiving a V-steam? If not, where have you had treatment previously?
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Reason and/or Intentions for Visit
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Do you have any major complaints or conditions that you want to improve? If so, list here. If none, enter N/A
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When did you first notice major complaints? What brought it on? If none, enter N/A
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Has there been a medical diagnosis? If so, by whom?
Please list ANY and ALL ALLERGIES. BE SPECIFIC. If none, enter N/A
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Contraindications
At what age did you begin your menses?
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Are you currently on your period?
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Do you have any interim bleeding (fresh pink or red spotting between periods, 2 periods per month, spontaneous bleeding)? Over the past month? Over the past 6 months?
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Is there any chance that you are currently pregnant?
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Are you trying to conceive?
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If yes, are you after your ovulation?
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Reproductive Health History
What was the first day of your last period?
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If your periods have stopped, when?
How often do your periods come?
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26 days or less
27-28 days
29 days or longer
Unsure
How long do they last? Example: 3 days? 4 days? 7 days?
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How many pregnancies have you had? If none, enter N/A
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Number of Deliveries? If none, enter N/A
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Terminations? If none, enter N/A
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Complications? If none, enter N/A
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Do you have any concerns about your menstrual cycle? If yes, please explain
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Are you under treatment for Infertility? If so, please describe CURRENT and PAST treatment(s)
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Check the symptoms/conditions that you're CURRENTLY experiencing:
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Abnormal Pap Smears
Acne
Adhesions/Scar Tissues
Amenorrhea (missed periods)
Anxiety
Bacterial Vaginosis (BV)
Bladder Infection
Bloating/ Water Retention
Cancer (please explain below)
Candida (Yeast Infection)
Cervical Issues
Chronic Miscarriage
Clotting
Cramps
Dark Blood at the beginning or end of cycle
Depression
Dysmenorrhea (excessively painful periods)
Edema in legs
Endometrosis
Excessive Bleeding
Failure to Ovulate
Fatigue
Fibroids/Cysts/Polyps
Headaches or Migraines with period
Heaviness in Pelvis with period
Hemorrhoids
Hormonal Imbalance
Hot Flashes
HPV
Incontinence/Frequent Urination
Infertility / Fertility Issues
Irregular Menses (early or late cycles)
Irregular Ovulation
Irritability/ Mood Swings
Low Back Pain with period
Low Libido
Menopausal Symptoms (Pre or Post)
Painful Intercourse
Painful Ovulation
Painful Periods
Polycystic Ovarian Syndrome (PCOS)
PMS
Poor Circulation
Postpartum Recovery
Sexually Transmitted Disease
Spotting/ Interim Bleeding
Uterine Fatigue/Weakness
Uterine Infections/UTI
Uterine Prolapse
Vaginal Discharge/Unhealthy Flora
Vaginal Dryness
Vaginal Infections
Womb Trauma
Other
If you checked CANCER, please explain in detail here. If not applicable, type N/A
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If you checked OTHER, please explain in detail here. If not applicable, type N/A
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List the symptoms/conditions that you've experienced in the PAST.
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Please list ANY ADDITIONAL information, condition, and/or symptom(s) that is relative to this treatment that we should know so that we may best customize your herb blend. Please be as detailed as possible.
Sensitivity Analysis
Have you experienced any hot flashes and/or night sweats over the past month?
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Do you have an IUD?
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Do you ever have yeast infections? If so, how often? Do you have one currently?
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Do you ever have bacterial infections? If so, how often? Do you have one currently?
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Do you ever have urinary tract infections? If so, how often? Do you have one currently?
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Do you have herpes?
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Have you been diagnosed with PCOS?
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Do you currently have fibriods or cysts? If so, please specify.
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Have you been diagnosed with Endometriosis?
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Do you currently have any STD's? If so, please specify.
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Do you have any other symptoms or conditions not listed above that affect your menses or reproductive health?
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Do you have any known contagious disease currently?
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Please list diseases prevalent on both your mother and father sides of your family: (i.e. diabetes, high blood pressure, cancers) on
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Do you have a medical diagnosis of any mental, personality, or social disorders? (i.e. Obsessive Compulsive Disorder, Anxiety Disorder, Bipolar Disorder, Hoarding, Schizophrenia).
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Yes
No
Other
If Yes, please explain
What medications (prescribed or over the counter), herbs, vitamins, supplements, etc..., are you currently taking? (also list why you are taking them)
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By signing below, you confirm that the information provided has been given voluntarily and answered honestly to the best of your ability. You also acknowledge that by clicking on the "Submit" button below, you are indicating your intent to sign the relevant document or record and that this will constitute your signature.
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