Vaginal Steam Intake Form

Personal Information

Name: _________________________________________________________ Date: ________________

Address: _______________________________________________________________________________

City / State / Zip: _______________________________________________________________________

Phone: ________________________________________ E-mail: ________________________________

Occupation: _______________________________________ Date of Birth: _____________ Age: _____

Referred by: __________________________________________________________________________

Emergency Contact

Name / Relationship / Phone: ______________________________________________________________

Reason for Visit

What are your intentions/expectations for this visit and what are your major complaints or conditions

you want to improve? ___________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

When did you first notice major complaints? _________________________________________________

______________________________________________________________________________________

What brought it on? _____________________________________________________________________

Has there been a medical diagnosis? _______________________________________________________

By whom? _______________________________________________________________________
Reproductive Health History

What was the first day of your last period? ____________ If they have stopped, when? _____________

How often do your periods come? ___________________ How long do they last? __________________

Episodes of Amenorrhea? _______________ When? ____________ For how long? __________________

Do you have any concerns about your menstrual cycle? ________________________________________

______________________________________________________________________________________

A.R.T.

Are you under treatment for Infertility? _____________________________________________________

Describe current treatment: (I.V.F, I.U.I etc) __________________________________________________

______________________________________________________________________________________

Describe past treatments: ________________________________________________________________

______________________________________________________________________________________

Pregnancy

Are you pregnant or trying to conceive? ____________________________________________________

How many pregnancies have you had? ____________ Number of Deliveries ____________

Terminations / When? _______________________ Miscarriages / When? _________________________

Complications __________________________________________________________________________

Deliveries:

Birth date Childs name Gender Complications

Please check as appropriate:

Menstrual & Ovulatory Symptoms Bladder Issues

Painful Periods Frequent Urination

Painful Ovulation Nocturnal Urination

Failure to Ovulate Difficult/Painful or Incomplete Urination

Dark Blood at beginning or end of cycle Chronic Bladder Infections

Clotting Incontinence

Low Back Pain with period Digestive Issues

Bloating / Water Retention Chronic Constipation

Excessive Bleeding Pain with Bowel Movements

Heaviness in Pelvis with period Straining

Irregular Menstrual Cycles Chronic Indigestion or Heartburn

Irregular Ovulation Other Digestive Issues

Spotting Pelvic Floor Stagnation

Hormonal Imbalance Painful Intercourse

PMS / Depression / Irritability Pelvic Pain

Headaches or Migraines with period Pain in Genital Area

Hot Flashes Low Libido

Fertility Sluggish Digestion

Infertility / Fertility Issues Rectal Pain

Polycystic Ovarian Syndrome (PCOS) Ovarian Cysts

Endometriosis Recurrent Vaginal Infections

Chronic Miscarriage Uterine Fibroids

Musculoskeletal Symptoms Uterine Infections

Pelvic Floor Stagnation Uterine Polyps

Adhesions / Scar Tissue Unexplained Low Back Pain

Uterine Prolapse Vaginal Dryness

Circulatory System Other

Varicose Veins Cancer - esp of the reproductive area

Hemorrhoids Vaginal Discharge

Restless Legs Womb Trauma

Edema in legs

Other symptoms not listed above: _________________________________________________________

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
• With any open wounds, sores, blisters or stitches
• If you have a vaginal infection or fever
• Piercings will need to be removed

Caution:


• If you have an IUD

Steams help release matter from the uterus. To date, there are no incidents of IUD's being released with vaginal
steam baths. They are on the caution list but no longer contraindicated. However, I will ask that if you have an IUD,
you sign a release form that you are aware of the possibility of your IUD releasing. 

Please take a moment to carefully read the following information and sign where indicated. If you have
a specific medical condition or specific symptoms, vaginal/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 vaginal/yoni steam baths should not be construed as a substitute for medical
examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified
medical specialist for any physical or mental ailment of which I am aware.

I understand that the practitioner facilitating the vaginal/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. Because 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 come out due to a Vaginal Steam
Bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk.

I understand that I am having this vaginal/yoni steam bath at my own risk and hereby release
___________________________________________________________ from any liability.

Client Name (printed): __________________________________________

Client Signature: _______________________________________________ Date: _________________