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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?
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:
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.)
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.
If yes, please explain
If yes, please explain
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.
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