To Each Is Om Yoni Steam Client Questionnaire

1
Practitioner Name
First Name
Last Name
2
Practitioners email address
example@example.com
3
Client Name * This field is required.
First Name
Last Name
4
Phone Number* This field is required.
Area Code
Phone Number
5
E-mail* This field is required.
example@example.com
6
Additional Information/Comments
7
Today Date
Date
Year
Month
Day
8
ContraindicationsThere 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.
Yes
NO
Not sure
Are you currently on your period?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Do you currently have fresh spotting?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Have you had spontaneous heavy bleeding within the past 3 months?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Are you pregnant?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
If trying to conceive are you past ovulation or IUI/IVF transfer
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Are you currently on your period?
Do you currently have fresh spotting?
Have you had spontaneous heavy bleeding within the past 3 months?
Are you pregnant?
If trying to conceive are you past ovulation or IUI/IVF transfer
Yes
Row 0, Column 0
NO
Row 0, Column 1
Not sure
Row 0, Column 2
Yes
Row 1, Column 0
NO
Row 1, Column 1
Not sure
Row 1, Column 2
Yes
Row 2, Column 0
NO
Row 2, Column 1
Not sure
Row 2, Column 2
Yes
Row 3, Column 0
NO
Row 3, Column 1
Not sure
Row 3, Column 2
Yes
Row 4, Column 0
NO
Row 4, Column 1
Not sure
Row 4, Column 2
1 of 5
9
Please respond to the questions below 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.
Yes
NO
Not sure
Do you have an infection characterized with a burning itch?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Do you have a birth control arm implant (i.e. nexplanon)?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Do you have an Essure insert?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
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?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Not sure
Row 0, Column 2
Yes
Row 1, Column 0
NO
Row 1, Column 1
Not sure
Row 1, Column 2
Yes
Row 2, Column 0
NO
Row 2, Column 1
Not sure
Row 2, Column 2
Yes
Row 3, Column 0
NO
Row 3, Column 1
Not sure
Row 3, Column 2
Yes
Row 4, Column 0
NO
Row 4, Column 1
Not sure
Row 4, Column 2
1 of 5
10
SensitivitiesSome 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.
Yes
NO
Not sure
Is this your first time doing a steam session?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Are your menstrual cycles currently or historically ever 27 days or shorter?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Have you experienced any hot flashes over the past month?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Have you experienced any nightsweats over the past month?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Do you have an IUD in?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Are you currently or historically prone to yeast infections?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Are you currently or historically prone to bacterial vaginosis?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Do you have herpes?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Do you have the nuva ring in? (If so, it should be removed prior to steam session)
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Are you age 13 or younger?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Do you have a history of spontaneous bleeding or two periods per month (3 months or later in the past)?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
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)?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Not sure
Row 0, Column 2
Yes
Row 1, Column 0
NO
Row 1, Column 1
Not sure
Row 1, Column 2
Yes
Row 2, Column 0
NO
Row 2, Column 1
Not sure
Row 2, Column 2
Yes
Row 3, Column 0
NO
Row 3, Column 1
Not sure
Row 3, Column 2
Yes
Row 4, Column 0
NO
Row 4, Column 1
Not sure
Row 4, Column 2
Yes
Row 5, Column 0
NO
Row 5, Column 1
Not sure
Row 5, Column 2
Yes
Row 6, Column 0
NO
Row 6, Column 1
Not sure
Row 6, Column 2
Yes
Row 7, Column 0
NO
Row 7, Column 1
Not sure
Row 7, Column 2
Yes
Row 8, Column 0
NO
Row 8, Column 1
Not sure
Row 8, Column 2
Yes
Row 9, Column 0
NO
Row 9, Column 1
Not sure
Row 9, Column 2
Yes
Row 10, Column 0
NO
Row 10, Column 1
Not sure
Row 10, Column 2
1 of 11
11
Cleansing Herb IndicatorsCleansing Herb Blend promotes circulation, balance the vaginal flora, improve scent, tone skin, clear out excess mucus and nourish the reproductive organs.
Yes
NO
Are your menstrual cycles 28 days or longer?
Row 0, Column 0
Row 0, Column 1
Is your menstrual cycle absent or missing for an unknown reason or because of birth control?
Row 1, Column 0
Row 1, Column 1
Are you currently taking birth control pills?
Row 2, Column 0
Row 2, Column 1
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?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Yes
Row 1, Column 0
NO
Row 1, Column 1
Yes
Row 2, Column 0
NO
Row 2, Column 1
1 of 3
12
Gentle Herb IndicatorsGentle Herb Blend help mildly clear the uterus from stagnation while also having the added benefit of possibly lengthening menstrual cycles and stopping fresh spotting or interim bleeding
Yes
NO
Do you ever have menstrual cycles 27 days or less?
Row 0, Column 0
Row 0, Column 1
Do you have fresh spotting between periods?
Row 1, Column 0
Row 1, Column 1
Are you currently underage 13?
Row 2, Column 0
Row 2, Column 1
Do you ever have menstrual cycles 27 days or less?
Do you have fresh spotting between periods?
Are you currently underage 13?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Yes
Row 1, Column 0
NO
Row 1, Column 1
Yes
Row 2, Column 0
NO
Row 2, Column 1
1 of 3
13
Disinfecting Herb IndicatorsDisinfecting Herb Blend help to kill bacteria, yeast and viruses while expelling toxins, reducing inflammation, getting rid of excess mucus, deodorizing and resetting the healthy flora in the reproductive tract.
Yes
NO
Do you have green vaginal discharge?
Row 0, Column 0
Row 0, Column 1
Do you have yellow vaginal discharge?
Row 1, Column 0
Row 1, Column 1
Do you have white vaginal discharge?
Row 2, Column 0
Row 2, Column 1
Do you have thick vaginal discharge?
Row 3, Column 0
Row 3, Column 1
Do you have malodorous vaginal discharge?
Row 4, Column 0
Row 4, Column 1
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?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Yes
Row 1, Column 0
NO
Row 1, Column 1
Yes
Row 2, Column 0
NO
Row 2, Column 1
Yes
Row 3, Column 0
NO
Row 3, Column 1
Yes
Row 4, Column 0
NO
Row 4, Column 1
1 of 5
14
Cooling Herb IndicatorsCooling Herb Blend help for those experiencing night sweats, hot flashes, dryness or living in hot climates. It includes herbs that help to nourish kidneys, moisturize and cool down, as well as increase the energy of blood flow and provide circulation.
Yes
NO
Do you have vaginal dryness?
Row 0, Column 0
Row 0, Column 1
Have you experienced hot flashes recently?
Row 1, Column 0
Row 1, Column 1
Have you experienced night sweats recently
Row 2, Column 0
Row 2, Column 1
Do you have any type of dry infection (without vaginal discharge)?
Row 3, Column 0
Row 3, Column 1
Is the weather currently very hot?
Row 4, Column 0
Row 4, Column 1
Do you have an aversion to heat?
Row 5, Column 0
Row 5, Column 1
Do you radiate heat?
Row 6, Column 0
Row 6, Column 1
Do you have 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)?
Is the weather currently very hot?
Do you have an aversion to heat?
Do you radiate heat?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Yes
Row 1, Column 0
NO
Row 1, Column 1
Yes
Row 2, Column 0
NO
Row 2, Column 1
Yes
Row 3, Column 0
NO
Row 3, Column 1
Yes
Row 4, Column 0
NO
Row 4, Column 1
Yes
Row 5, Column 0
NO
Row 5, Column 1
Yes
Row 6, Column 0
NO
Row 6, Column 1
1 of 7
15
AllergiesDo you have any food/plant allergies?
Huge
Large
Normal
Small
Ok
Ok
16
Excess Heat Indicator Please answer yes or no to each question below> If Yes, indicate excess heat we will use a steam gown, NO Blanket, or towel over you.
Yes
NO
Do you have hot flashes?
Row 0, Column 0
Row 0, Column 1
Do you have nightsweats?
Row 1, Column 0
Row 1, Column 1
Do you radiate heat??
Row 2, Column 0
Row 2, Column 1
Are you prone to infections or viruses?
Row 3, Column 0
Row 3, Column 1
Is it hot weather?
Row 4, Column 0
Row 4, Column 1
Do you have an aversion to heat?
Row 5, Column 0
Row 5, Column 1
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?
Yes
Row 0, Column 0
NO
Row 0, Column 1
Yes
Row 1, Column 0
NO
Row 1, Column 1
Yes
Row 2, Column 0
NO
Row 2, Column 1
Yes
Row 3, Column 0
NO
Row 3, Column 1
Yes
Row 4, Column 0
NO
Row 4, Column 1
Yes
Row 5, Column 0
NO
Row 5, Column 1
1 of 6
17
No PeriodIf 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
18
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.
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.
19
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.
20
THIS AGREEMENT is made between To Each Is Om Yoga and Wellness, LLC and (collectively the “Parties”).

I have purchased or am receiving steaming services, products or a consultation from To Each Is Om Yoga and Wellness, LLC (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 To Each Is Om Yoga and Wellness, LLC. I further affirm, that all information provided to To Each Is Om Yoga and Wellness, LLC 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 To Each Is Om Yoga and Wellness, LLC 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 To Each Is Om Yoga and Wellness, LLC premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release To Each Is Om Yoga and Wellness, LLC, 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.toeachisom.com that To Each Is Om Yoga and Wellness, LLC 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.

To Each Is Om Yoga and Wellness, LLC, 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 To Each Is Om Yoga and Wellness, LLC, 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 To Each Is Om Yoga and Wellness, LLC 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 To Each Is Om Yoga and Wellness, LLC 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 Georgia 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.
21
Signature
Clear
22
Todays Date
Date
Year
Month
Day
23
OM -Yoni Steam Practitioner Use only Set up best for client
Yes
NO
Steaming is Contraindicated
Row 0, Column 0
Row 0, Column 1
Mild Session
Row 1, Column 0
Row 1, Column 1
Advanced Session
Row 2, Column 0
Row 2, Column 1
Cleansing Herbs
Row 3, Column 0
Row 3, Column 1
Gentle Herbs
Row 4, Column 0
Row 4, Column 1
Disinfecting Herbs
Row 5, Column 0
Row 5, Column 1
Cooling Herbs
Row 6, Column 0
Row 6, Column 1
Goddess Gown
Row 7, Column 0
Row 7, Column 1
Goddess Gown w/out blanket
Row 8, Column 0
Row 8, Column 1
Steaming is Contraindicated
Mild Session
Advanced Session
Cleansing Herbs
Gentle Herbs
Disinfecting Herbs
Cooling Herbs
Goddess Gown
Goddess Gown w/out blanket
Yes
Row 0, Column 0
NO
Row 0, Column 1
Yes
Row 1, Column 0
NO
Row 1, Column 1
Yes
Row 2, Column 0
NO
Row 2, Column 1
Yes
Row 3, Column 0
NO
Row 3, Column 1
Yes
Row 4, Column 0
NO
Row 4, Column 1
Yes
Row 5, Column 0
NO
Row 5, Column 1
Yes
Row 6, Column 0
NO
Row 6, Column 1
Yes
Row 7, Column 0
NO
Row 7, Column 1
Yes
Row 8, Column 0
NO
Row 8, Column 1
1 of 9
Should be Empty: