Menstruator Evaluation Name * First Name Last Name Phone (###) ### #### Email * Evaluation Standard Healthy Cycle Assessment Cycle Length = 28-30 Days Yes Needs Work Period Length = 4 Days Yes Needs Work Menses = Healthy Red (No Other Color) Yes Needs Work Flow (Medium + Even) Yes Needs Work Vaginal Discharge = Clear Nectar Yes Needs Work Symptom Free Yes Needs Work Proper Period Care Yes Needs Work Aduquate Period Rest Yes Needs Work Moon Proximity Imbalances Uterine Fatigue Yes - Current Imbalance In the past but not now No Dampness Yes - Current Imbalance In the past but not now No Stagnation Yes - Current Imbalance In the past but not now No Blood Deficiency Yes - Current Imbalance In the past but not now No Dryness Yes - Current Imbalance In the past but not now No Excess Heat Yes - Current Imbalance In the past but not now No Weak Digestion Yes - Current Imbalance In the past but not now No Medical Negligence Yes No Possibly Evaluation Notes Steam Plan - Re-evaluate after every menstrual cycle Steam Indication Yes - Steaming is safe at this time No - Steaming should not take place Contraindication Type Uterine Bleeding Contraindication Pregnancy Contraindication Medical Contraindication Excess Heat Contraindication Contraindication Recommendation There is soft containdication to discuss further Only an herbal bath is recommended at this time Wait to steam See referral First Aid Care Go on bedrest immediately to slow down bleeding See local acupuncturist to slow or stop bleeding (ask about yunnan baiyao or gui pi pian or moxa) If still bleeding by period day 5 go to an acupuncturist to stop bleeding First aid herbal remedies See first aid herbal remedies for home remedies and herbs to keep in the medicine cabinet at home. Please read this article about first aid to stop bleeding and important safety signs to watch out for: https://steamychick.institute/firstaid Practitioner Notes Steam Sensitivities Uterine Bleeding Sensitivity Medical Sensitivity Heat Sensitivity Age Sensitivity First Timer Steam Set up Yes Heater No Heater Steam Duration 5 minutes 10 minutes 30 minutes 40 minutes + lay down afterwards Session Frequency One Steam Session Per Day Two Steam Sessions Per Day (morning and evening) Add Additional Sessions as Desired Night Time Session Before Bed Cloak Yes No Steam Herb Formula Hemostatic Cooling Disintecting Cleansing Salt Salt (½ teaspoon per 6 cups water/ 1.5 quarts/ 1.5 liters) Apple Cider Vinegar (2 tablespoons per 6 cups water/1.5 quarts/1.5 liters) Do not use herbs. Use water only. Herb Dosage Normal Dosage Use only half the normal dosage Use double the normal dosage Steam Schedule Recommendation Daily 3 Days in a Row 3 Days on 3 Days Off 10 Days in a Row 30 Days in a Row 90 Days in a Row After Period 1x Before Period 3x Before Period 3x After Period Menstrual Cycle Days 19/20/21 Menstrual Cycle Days 23/24/25 Menstrual Cycle Days 5/6/7/13 Menstrual Cycle Day 20 Menstrual Cycle Day 25 Menstrual Cycle Days 31/32/33 Menstrual Cycle Days 31/34/37/40 etc Basic Uterine Cleanse (3x after period and 3x before period - MC Days 23/24/25 - modify for shorter cycles) Intermediate Uterine Cleanse (5x after period and 5x before - MC Days 21/22/23/24/25 - modify for shorter cycles) Advanced Uterine Cleanse - (start out every othre day and then turn it up to daily) Weekly (optional with the moon) Bimonthly (optional - new moon/full moon) Monthly (optional with the moon) Pre-Ovulation Pre-Sex Post-Sex Post-Bowel Movement Pre-Sleep ASAP Prior to vaginal medical exam or procedure to remove chance of injury After medical exam or procedure to remove chance of infection/cross-contamination Steam at first sign of issue Other Steam Target Area Vaginal Canal Rectum Other Additional Recommendations Pause inseminatoin until uterus is healthy (Standard Healthy Cycle) Inseminate only on menstrual cycle days 13/14/15 Steam Resources Steam User Type Uterine Cleanse Stagnatrion Uterine Fatigue Blood Deficiency Dampness Dryness Excess Heat Weak Digestion Practitioner Notes Referrals Acupuncturist Medical Doctor Midwife Doula Therapist or Healer Pelvic Floor Physical Therapist Abdominal Massage Practitioner Sex Therapist Scar Tissue Remediation Expert Nutritionist Referral Notes and Contact Information Practitioner Notes Steam Records Follow Up Appointment Recommended Yes Not at this time Type of Appointment Post-Period Evaluation and Menstrual Cycle Analysis Steam Plan Follow Up Healthy Sex Guidelines Consultation Womb Cleanse Care Consultation Date of Next Appointment Good Job!
