Email

Emergency Contact

Name & Phone Number

What is your reason for doing a steam session?

Has your pelvic anatomy altered at all since birth due to voluntary or medical surgery or alterations?

Preferred Gender Pronouns

There are times when it is not beneficial for someone to steam. As a first step, let’s check and make sure that you are safe for a steam session.

Hard Contraindications: Uterine Bleeding Contraindications

Hard Contraindications: Pregnancy Contraindications

What else should I know?

Soft Contraindications : Uterine Bleeding Contraindications

Soft Contraindications : Medical Contraindications

What else should I know?

Steam Sensitivities

Some people 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. Let's see if you have any sensitivities.

Uterine Bleeding Sensitivity

Medical Sensitivity

Heat Sensitivity

First Timer

What else should I know?

No Periods

If you had periods in the past but don't have them now, how long ago was your last period?

Cycle Length

Let's determine the length of your cycle. This would be the amount of days from day one of the period to the start of the next period. Menstruators commonly report that their cycle is 28 days but it is rare for the cycle to always be 28 days. It usually fluctuates and looking at the variations in length can reveal important information about menstrual health. In order to get a proper determination of your cycle length please list the length of your past 6 cycles. If you use a period app, it may automatically calculate this information for you. If you do not use a period app, you can use the calendar where you mark down your periods. Count from day one of the period until the day before your next period starts. That'll be overall cycle length. If you do not use an app or calendar, please leave the form blank and use the notes section to write any info about how long you think it might be.

What is Your Current Menstrual Cycle Day?

For example if you started your period on the 9th and today is the 15th you would count the 9th as day 1, 10th as day 2, 11th as day 3, 12th as day 4, 13th as day 5, 14th as day 6, 15th as day 7. You would currently be on menstrual cycle day 7.

Please Include Infromation Abour Your Previous Six Menstrual Cycles

What age were you when you had your first period?

Please provide further information if relevant

Information About Your Last Period

Each period is a snapshot of your current state of health during this month. In general, menstruator's health can change significantly from cycle to cycle. For this reason it's very useful to look at the signs from your very last period to see exactly what those signs tell us about your health at this moment in time. Please fill out the following sections and mark "Yes" ONLY if that symptom occurred on your very last period or cycle. Finally, there is a notes section at the end where you can include any more information that you think might be relevant about these specific signs. If you do not currently have periods please do your best to fill out information about your last period marking the column "It's been a long time". There will also be some indicators and questions below that are not period-related. Please answer those accordingly.

Uterine Fatigue Indicators

For any yes or not sure answers please give as much info as possible

Stagnation Indicators

Have you had any abdominal surgeries or procedures that have created scar tissue or stagnation? Please explain.

For any yes signs please give as much info as possible

Blood Deficiency

If you answered yes to absent periods, have there been any suprising life changes since your last period that might have stopped your natural cycle? (examples: major event, breakup, job change, move, death in the family).

For any yes signs please give any relevant information

Heat Indicators

Have you been diagnosed by a doctor with an infection or virus? If so, please include more information. If not diagnosed by a doctor, why do you think you have an infection?

Dryness Indicators

For any yes signs please give as much info as possible

Dampness

For any yes signs please give as much info as possible

Weak Digestoin Indicators

Please add any further notes if you wish

Standard Healthy Cycle

Let's do a quick little check list and see how your last cycle compares to a standard healthy cycle

Period Length (from first spot to last spot)

Last Menstrual Cycle Length

Menses Colors During Last Period (red, brown, black, pink, orange, purple, clear)

Flow Strength During Last Period (light, medium, heavy, flooding, start and stop, clotted, stringy)

Menstrual Cycle Symptoms

What else should I know

Proper Period Care

There are certain lifestyle behaviors and products that really help to improve overall menstrual cycle health. This is known as proper period care or period pampering. Let's see how you're doing.

Inadequate Period Rest

A healthy period lasts for 4 days of fresh bleeding. In order for the period to stop on day 5 the body needs adequate rest during days 1-4 of the period. Inadequate period rest during days 1-4 of the period can result in periods with 5 days or longer of fresh bleeding. Let's check to see if you have any signs of inadequate period rest.

Allergies

Please list any plant or food allergies

Reproductive Questionnaire

Number of Pregnancies

Child(ren) Age(s)

Number of Live Births

How long did it take for the postpartum menstrual return?

More Information

Additional Screening

Do you have any major health concerns?

Do you have pelvic organ prolapse? If so, please describe.

Do you have hemorrhoids, rectal prolapse or anal fistula? If yes, please describe. Makre sure to indicate if there is any burning sensation or bleeding.

Do you have labial adhesion?

Medical Questionnaire

Physician Name

Are you taking any medications or artificial hormones?

Has your primary care giver given you any current recommendations that you are or are not following? If so, please describe.

Have you had any surgeries or operations? If so, are you still in the immediate recovery time? How long is the expected recovery time? What does the recovery involve?

Further Notes

Steam Questionnaire

What is your experience with Pelvic Steaming? (Please indicate if you have ever done it before. If you have done it please describe your experience, period changes, herbs and setup used and any questions or complications.)

What is the main concern that you have that you would like to address?

Do you have any questions before your Vaginal Steam session?

[STEAM VAGINAL HEALTH] INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORMTHIS AGREEMENT is made between Steam Vaginal Health and I (collectively the “Parties”). I have purchased or am receiving complimentary steaming services, products or a consultation from Steam Vaginal Health (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 Steam Vaginal Health or its agents. I further affirm that all information provided to Steam Vaginal Health 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 Steam Vaginal Health 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 the Steam Vaginal Health premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release Steam Vaginal Health, 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.steamychick.com that Steam Vaginal Health’s 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. Steam Vaginal Health, 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 Steam Vaginal Health, 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 Steam Vaginal Health, 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 Steam Vaginal Health 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 governing body that the practitioner resides in and any dispute under this Agreement must be brought to a court in this locality 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. If under 18 please have the parent/guardian sign and provide the child’s name to the side.

STEP 1.

Pre-Steam

Advisories

STEP 2.

Tell Me More!

Thank you so much for all of the information. You are all set for your appointment.

XO,

steam. Team

Location

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