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Intake Form

Yoni/ Vaginal Steam 

BASIC INFORMATION

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

Are you currently on your period?
Yes
No
Not Sure
Do you currently have fresh spotting?
Yes
No
Not Sure
Have you had spontaneous bleeding within the past 3 months?
Yes
No
Not Sure
Have you had two periods per month in the past 3 months?
Yes
No
Not Sure
Are you currently pregnant?
Yes
No
Not Sure
If trying to conceive are you past ovulation?
Yes
No
Not Sure
Do you currently have viral infection with vomiting or diarrhea?
Yes
No
Not Sure
On prescription medication, including beta blockers, diuretics or barbiturates can affect your heart rate or interfere with your body's natural ability to sweat. Make sure to check with your doctor about side effects of your medications.
Yes
No
Not Sure
Heart disease, hypertension, hypotension, hyperthyroidism, hemophilia, diabetes, cancer, Parkinson's, systemic lupus erythematous, or adrenal suppression and multiple sclerosis.
Yes
No
Not Sure

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

Do you have an infection characterized with a burning itch?
Yes
No
Not Sure
Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?
Yes
No
Not Sure
Do you have a birth control arm implant (i.e. nexplanon)?
Yes
No
Not Sure
Do you have an IUD birth control (i.e. mirena)?
Yes
No
Not Sure

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.

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 perfectly suits you.

Is this your first time doing a steam session?
Yes
No
Not Sure
Are your menstrual cycles currently or historically ever 27 days or shorter?
Yes
No
Not Sure
Have you experienced any hot flashes over the past month?
Yes
No
Not Sure
Have you experienced any night sweats over the past month?
Yes
No
Not Sure
Do you have an IUD in?
Yes
No
Not Sure
Are you currently or historically prone to yeast infections?
Yes
No
Not Sure
Are you currently or historically prone to bacterial vaginosis?
Yes
No
Not Sure
Do you have herpes?
Yes
No
Not Sure
Do you have the nuva ring in? (If so, it should be removed prior to steam session)
Yes
No
Not Sure
Are you age 13 or younger?
Yes
No
Not Sure
Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)?
Yes
No
Not Sure

The above "yes" replies indicate sensitivity in which case a mild setup which should be performed 10-15 minutes.Under no circumstances should clients who have sensitivity use an advanced setup which is 25- 30 minute steam sessions.

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 Restore/Cleansing Herbs

Are your menstrual cycles 28 days or longer?
Yes
No
Is your menstrual cycle absent or missing for an unknown reason or because of birth control?
Yes
No
Are you currently taking birth control pills?
Yes
No

Indicators for Align/Gentle Herbs

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

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

Indicators for Detox/Disinfecting Herbs 

Do you have green vaginal discharge?
Yes
No
Sometimes
Do you have yellow vaginal discharge?
Yes
No
Sometimes
Do you have white vaginal discharge?
Yes
No
Sometimes
Do you have thick vaginal discharge?
Yes
No
Sometimes
Do you have malodorous vaginal discharge?
Yes
No
Sometimes

Indicators for Rebalance/Cooling Herbs

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

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

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

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.

Waiver

PLEASE BE ADVISED

Most of the side-effects reported while steaming are positive. Users have reported better sleep and lucid dreams, relaxation, decreased swelling in legs and feet, decreased abdominal bloating, slimmer waistline, increased libido and sexual sensation; increased vaginal nectar and fertility, decrease in breast soreness, fewer headaches, fewer PMS symptoms and improved emotional balance, increased circulation and energy, tingling feet, glowing skin, reduction in incidence of hormonal acne and increased lubrication and vaginal nectar, scar softening, tighter vaginal canal and harmonization with the moon cycle.


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 let your practitioner know of these positive changes.


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.


4) Having a plant based diet will drastically help your life and the health of your vagina. Incorparte more fresh fruits and vegtables.


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 protocol 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 99% of all 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.


I understand that vaginal steaming may have positive or negative side effects as a result of doing a vaginal steam session. I accept legal responsibility for my choice to do a vaginal steam session and waive the responsibility of the practitioner and the facility where the steam session takes place in the case that any of the named side effects (or others) may occur.

Please Print and sign your name below to confirm you understand all of the benifits steaming will provide.

Date of Signature