Practitioner Intake Form Name * First Name Last Name Phone (###) ### #### Email * Steam plan 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 Practitioner Notes Steam Sensitivities Uterine Bleeding Sensitivity Medical Sensitivity Heat Sensitivity Age Sensitivity First Timer Steam Set up Yes Heater No Heater Steam Duration 10 minutes 30 minutes 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. Steam Schedule Recommendation Weekly 3 days in a row before period + 3 days in a row after period Referrals Peristeam Hydrotherapist Acupuncturist Medical Doctor Midwife Therapist or Healer Pelvic Floor Physical Therapist Abdominal Massage Practitioner Other Text Referral Notes and Contact Information Steam Resources Text Practitioner Notes Good Job!
