V-Steam Intake Form

V-Steam Intake Form
Today’s date

MonthDayYear
Date
First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contraindication Screening
Are you currently on your period (fresh menses)?

YesNo
Do you have any interim bleeding (fresh pink or red spotting between periods, 2 periods per month, spontaneous bleeding)?

YesNo
Over the past month?

YesNo
Over the past 6 months?

YesNo
Is there any chance that you are currently pregnant?

YesNo
Are you trying to conceive?

YesNo
If yes, are you after your ovulation?

YesNo
Sensitivity Screening
Is this your first time doing a vaginal steam session?

YesNo
Are your cycles 27 days or fewer?

YesNo
Have you experienced any hot flashes over the past month?

YesNo
Do you have an IUD?

YesNo
Do you ever have yeast infections?

YesNoType option 3
Do you ever have bacteria infections?

YesNo
Do you ever have urinary tract infections?

YesNo
Do you have herpes?

YesNo
Age?
Have you or anyone in your family, friends or work environment been exposed or tested positive for COVID-19?

YesNo
Excess heat screening
Do you experience any of the following?*

Night sweatsHot flashesInfectionsHerpesRadiating HeatNone of the above
Herb Selection

Mark any that apply and then make the best selection.
Cleansing*

Cycle = 28 days or longerMissing CycleOral ContraceptivesNone of the above
Gentle*

Short Cycles = 27 days or lessFresh Spotting Between PeriodsUnderage 13None of the above
Disinfecting

Yeast InfectionsBacteria InfectionsVirusesNone of the above
Cooling

Vaginal DrynessHot ClimatesNightsweats/HotflashesNone of the above
SETUP (for office use)

Is the client contraindicated to steam? _____yes _____ no

Is the client sensitive? _____ yes _____ no

Which setup is best for client?

______ Mild Setup _____ Advanced Setup

Does the client have excess heat?

______ Cloak _____ No Cloak

Which Herb Selection is Best?

_____ Cleansing Herbs

_____ Disinfecting Herbs

______ Gentle Herbs

______ Cooling Herbs
Should be Empty: