Intake Form – Queen Bee Yoni Pot

Client Intake Form

This Intake form must be filled out and accepted in order to receive any services at Queen Bee Yoni Pot Spa. If you need additional information or have questions feel free to contact us and we will gladly assist.

Full Name

Date Of Birth

Street

Suite-Apt

City

State

Zip Code

Phone

Emergency Contact

Full Name

Relationship

Phone

Reason for Visit

What are your intentions/expectations for this visit and what are your major concerns or conditions you want to improve?

Are you apart of a group or party? If so, what is the name of the party or person who you are booked under and what is the date of the event.

When did you first notice your concerns?

Has there been a medical diagnosis?

Yes No

If so, by whom?

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 of the contraindications:

Are you currently on your period?

Yes No Not Sure I am experiencing Menopause. Skip the Reproductive Health History portion of the intake form.

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

Have you had any type of vaginal procedure in the past 2 months?

Yes No Not Sure

Are you pregnant?

Yes No Not Sure

If trying to conceive are you past ovulation?

Yes No Not Sure

Important: The above “Yes” replies indicate that vaginal steaming in 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.

When Yoni steams should be avoided:

If you are pregnant or there is a possibility of pregnancy
During or after ovulation if you are trying to conceive
During menstruation
Fresh spotting or spontaneous bleeding
With any open wounds, sores, blisters or stitches
If you have a vaginal infection or fever
Piercings will need to be removed
Birth control implant (Nexplanon, Implanon)
Infection with burning
Tubal Coagulation

Caution:

If you have an IUD, Yoni steams help release matter from the IUD. Steaming is not recommended.

Reproductive Health History

When was the first day of your last period?

How often do your periods come?

How long do they last?

Do you have any concerns about your menstrual cycle? If so explain.

How old were you when you started your period?

Are you under treatment for Infertility? If yes, describe current treatment: (I.V.F, I.U.I etc.)

Are you pregnant or trying to conceive?

Yes No Not Sure

Is there a chance of you being pregnant?

Yes No Not Sure

Are you currently on birth control?

Yes No

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?

Yes No Not Sure

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 every 27 days or shorter?

Yes No Not Sure In Menopause

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 ?

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

Are you currently or historically prone to yeast infections?

Yes No Not Sure

If yes, please explain

Are you currently or historically prone to bacterial vaginosis?

Yes No Not Sure

If yes, please explain

Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)?

Yes No Not Sure

If yes, please explain

Waiver

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, yoni steam baths may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner so that the temperature may be adjusted to my level of comfort. I further understand that yoni steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a medical provider, or other qualified medical specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the yoni steam bath is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Vaginal/yoni steam baths should not be performed under certain medical conditions. I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand . that there shall be no liability on the practitioner's part should I forget to do so. I am aware and I understand there is a possibility that my IUD can be released due to a Yoni Steam Bath. This has been explained to me and I am to proceeding with the Yoni Steam Bath at my own risk.

Print your full name if you agree to all the information above and that you answered and agree to the waiver information above.

Agree to the terms

Check the box if you agree to all the information above and agree to all the terms in this waiver. You also acknowledge you are NOT pregnant. You will be required to provide a signature of this waiver before your procedure.

Photo release

Check the box if you agree to have your picture used on our social media platforms.

How did you hear about us? (Facebook, Google, Yelp, Friend, etc.)

Client Intake Form

Contraindications:

Reproductive Health History

Sensitivities

Waiver

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