V-Steam Intake Form

V-Steam Intake Form
10-31-2020

Month Day Year
Date
First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

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

Yes No
Do you have any interim bleeding (fresh pink or red spotting between periods, 2 periods per month, spontaneous bleeding)?

Yes No
Over the past month?

Yes No
Over the past 6 months?

Yes No
Is there any chance that you are currently pregnant?

Yes No
Are you trying to conceive?

Yes No
If yes, are you after your ovulation?

Yes No
Sensitivity Screening
Is this your first time doing a vaginal steam session?

Yes No
Are your cycles 27 days or fewer?

Yes No
Have you experienced any hot flashes over the past month?

Yes No
Do you have an IUD?

Yes No
Do you ever have yeast infections?

Yes No Type option 3
Do you ever have bacteria infections?

Yes No
Do you ever have urinary tract infections?

Yes No
Do you have herpes?

Yes No
Age?
Have you or anyone in your family, friends or work environment been exposed or tested positive for COVID-19?

Yes No
Excess heat screening
Do you experience any of the following? *

Night sweats Hot flashes Infections Herpes Radiating Heat None of the above
Herb Selection

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

Cycle = 28 days or longer Missing Cycle Oral Contraceptives None of the above
Gentle *

Short Cycles = 27 days or less Fresh Spotting Between Periods Underage 13 None of the above
Disinfecting

Yeast Infections Bacteria Infections Viruses None of the above
Cooling

Vaginal Dryness Hot Climates Nightsweats/Hotflashes None 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: