Vaginal Steam Intake

Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####
Today's Date Today's Date / MM / DD YYYY
What are your steaming goals? What results are you seeking?
How to answer the questions on this Intake...

Any questions asking about your current situation should be answered based on what you're experiencing with your cycle today (the day you're filling out the form).

All other questions referring to "recent menstrual history" should be answered based on your prior menstrual history going back about 3-6 months and what you would consider 'typical' for your cycle. If you are currently pregnant or newly postpartum, please answer these questions based on your menstrual history prior to your current or most recent pregnancy.
Contraindications

The following two sections screen for any steaming contraindications that suggest steaming should not be performed, that you should be referred out for additional supportive care before steaming is safe, or that adjustments should be made to personalize your steam plan and/or herbs.
Hard Contraindications

There are times when it is not beneficial for a woman to steam. First, let's check and make
sure that there are no hard contraindications.

Any of the following "Yes" replies indicate that vaginal steaming is 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.

Please select any of the following that apply:
	Yes	No	Not Sure
Are you currently on your period?	Are you currently on your period?Yes	Are you currently on your period?No	Are you currently on your period?Not Sure
Have you had two periods per month in your recent menstrual history?	Have you had two periods per month in your recent menstrual history?Yes	Have you had two periods per month in your recent menstrual history?No	Have you had two periods per month in your recent menstrual history?Not Sure
Have you had spontaneous bleeding in your recent menstrual history?	Have you had spontaneous bleeding in your recent menstrual history?Yes	Have you had spontaneous bleeding in your recent menstrual history?No	Have you had spontaneous bleeding in your recent menstrual history?Not Sure
Are you currently pregnant?	Are you currently pregnant?Yes	Are you currently pregnant?No	Are you currently pregnant?Not Sure
Are you actively trying to conceive pregnancy (including IUI, IVF, etc)?	Are you actively trying to conceive pregnancy (including IUI, IVF, etc)?Yes	Are you actively trying to conceive pregnancy (including IUI, IVF, etc)?No	Are you actively trying to conceive pregnancy (including IUI, IVF, etc)?Not Sure
Have you had any uterine or abdominal surgeries in the past 6 weeks (ex: cesarean, appendectomy, myomectomy, ovarian cyst removal, etc)?	Have you had any uterine or abdominal surgeries in the past 6 weeks (ex: cesarean, appendectomy, myomectomy, ovarian cyst removal, etc)?Yes	Have you had any uterine or abdominal surgeries in the past 6 weeks (ex: cesarean, appendectomy, myomectomy, ovarian cyst removal, etc)?No	Have you had any uterine or abdominal surgeries in the past 6 weeks (ex: cesarean, appendectomy, myomectomy, ovarian cyst removal, etc)?Not Sure

Are you newly (0-6 months) postpartum?

Are you newly (0-6 months) postpartum? No Yes. When did you give birth? Yes. When did you give birth?
If you are newly postpartum, did you give birth...

If you are newly postpartum, did you give birth... vaginally cesarean
If you are currently pregnant, when is your due date? If you are currently pregnant, when is your due date? / MM / DD YYYY
Soft Contraindications

- If you are using the following 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 an infection that presents as 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 or other provider to get the burning sensation to go away prior to doing a vaginal steam session.

Please select any of the following that apply:
	Yes	No	Not Sure
Do you have an infection characterized with a burning itch?	Do you have an infection characterized with a burning itch?Yes	Do you have an infection characterized with a burning itch?No	Do you have an infection characterized with a burning itch?Not Sure
Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?	Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?Yes	Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?No	Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?Not Sure
Do you have a birth control arm implant (i.e. nexplanon)?	Do you have a birth control arm implant (i.e. nexplanon)?Yes	Do you have a birth control arm implant (i.e. nexplanon)?No	Do you have a birth control arm implant (i.e. nexplanon)?Not Sure
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?	Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?Yes	Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?No	Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?Not Sure
Do you have an Essure insert?	Do you have an Essure insert?Yes	Do you have an Essure insert?No	Do you have an Essure insert?Not Sure

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.
Any of the following "Yes" replies indicate sensitivity in which case a mild setup without a burner should be used. Under no circumstances should clients who have sensitivity use an advanced setup with a burner.

Please select any of the following that apply:
	Yes	No	Not Sure
Is this your first time doing a steam session?	Is this your first time doing a steam session?Yes	Is this your first time doing a steam session?No	Is this your first time doing a steam session?Not Sure
Are your menstrual cycles currently or historically ever 27 days or shorter?	Are your menstrual cycles currently or historically ever 27 days or shorter?Yes	Are your menstrual cycles currently or historically ever 27 days or shorter?No	Are your menstrual cycles currently or historically ever 27 days or shorter?Not Sure
Have you experienced any hot flashes over the past month?	Have you experienced any hot flashes over the past month?Yes	Have you experienced any hot flashes over the past month?No	Have you experienced any hot flashes over the past month?Not Sure
Have you experienced any nightsweats over the past month?	Have you experienced any nightsweats over the past month?Yes	Have you experienced any nightsweats over the past month?No	Have you experienced any nightsweats over the past month?Not Sure
Do you have an IUD in?	Do you have an IUD in?Yes	Do you have an IUD in?No	Do you have an IUD in?Not Sure
Are you currently or historically prone to yeast infections?	Are you currently or historically prone to yeast infections?Yes	Are you currently or historically prone to yeast infections?No	Are you currently or historically prone to yeast infections?Not Sure
Are you currently or historically prone to bacterial vaginosis?	Are you currently or historically prone to bacterial vaginosis?Yes	Are you currently or historically prone to bacterial vaginosis?No	Are you currently or historically prone to bacterial vaginosis?Not Sure
Do you have genital herpes?	Do you have genital herpes?Yes	Do you have genital herpes?No	Do you have genital herpes?Not Sure
Do you have the nuva ring in? (If so, it should be removed prior to steam session)	Do you have the nuva ring in? (If so, it should be removed prior to steam session)Yes	Do you have the nuva ring in? (If so, it should be removed prior to steam session)No	Do you have the nuva ring in? (If so, it should be removed prior to steam session)Not Sure
Are you age 13 or younger?	Are you age 13 or younger?Yes	Are you age 13 or younger?No	Are you age 13 or younger?Not Sure
Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)?	Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)?Yes	Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)?No	Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)?Not Sure

Are you currently trying to conceive?

Are you currently trying to conceive? Yes No
Period Symptoms

Please select your answer based on your last three menstrual cycles. If you have been without a period for several months, please select your answers based on your most recent menstrual history.

Please select any of the following that apply:
	Yes	No	Sometimes
Does your period start with brown blood?	Does your period start with brown blood?Yes	Does your period start with brown blood?No	Does your period start with brown blood?Sometimes
Does your period end with brown blood?	Does your period end with brown blood?Yes	Does your period end with brown blood?No	Does your period end with brown blood?Sometimes
Is your menstrual flow typically thick, dark and/or heavy?	Is your menstrual flow typically thick, dark and/or heavy?Yes	Is your menstrual flow typically thick, dark and/or heavy?No	Is your menstrual flow typically thick, dark and/or heavy?Sometimes
Do you normally have clots with your menstrual flow?	Do you normally have clots with your menstrual flow?Yes	Do you normally have clots with your menstrual flow?No	Do you normally have clots with your menstrual flow?Sometimes
Do you normally have cramps before, during and/or right after menstruation?	Do you normally have cramps before, during and/or right after menstruation?Yes	Do you normally have cramps before, during and/or right after menstruation?No	Do you normally have cramps before, during and/or right after menstruation?Sometimes

How many days does your period normally last?
How many days does your full cycle normally last?
Herb Selection

It is best to select herbs suitable to your constitution. Your practitioner will use the info from this intake form to select a suitable vaginal steam formula for you.
Indicators for Cleansing Herbs:

Please select any of the following that apply:
	Yes	No
Are your menstrual cycles 28 days or longer?	Are your menstrual cycles 28 days or longer?Yes	Are your menstrual cycles 28 days or longer?No
Is your menstrual cycle absent or missing for an unknown reason or because of birth control?	Is your menstrual cycle absent or missing for an unknown reason or because of birth control?Yes	Is your menstrual cycle absent or missing for an unknown reason or because of birth control?No
Are you currently taking birth control pills?	Are you currently taking birth control pills?Yes	Are you currently taking birth control pills?No

Indicators for Gentle Herbs:

If there are any "Yes" signs for the Gentle herbs this formula will always be the best choice.

Please select any of the following that apply:
	Yes	No
Do you ever have menstrual cycles 27 days or less?	Do you ever have menstrual cycles 27 days or less?Yes	Do you ever have menstrual cycles 27 days or less?No
Do you have fresh spotting between periods?	Do you have fresh spotting between periods?Yes	Do you have fresh spotting between periods?No
Are you currently under age 13?	Are you currently under age 13?Yes	Are you currently under age 13?No

Indicators for Disinfecting Herbs:

Please select any of the following that apply:
	Yes	No	Sometimes
Do you have green vaginal discharge?	Do you have green vaginal discharge?Yes	Do you have green vaginal discharge?No	Do you have green vaginal discharge?Sometimes
Do you have yellow vaginal discharge?	Do you have yellow vaginal discharge?Yes	Do you have yellow vaginal discharge?No	Do you have yellow vaginal discharge?Sometimes
Do you have white vaginal discharge?	Do you have white vaginal discharge?Yes	Do you have white vaginal discharge?No	Do you have white vaginal discharge?Sometimes
Do you have thick vaginal discharge	Do you have thick vaginal dischargeYes	Do you have thick vaginal dischargeNo	Do you have thick vaginal dischargeSometimes
Do you have malodorous vaginal discharge (smells bad)?	Do you have malodorous vaginal discharge (smells bad)?Yes	Do you have malodorous vaginal discharge (smells bad)?No	Do you have malodorous vaginal discharge (smells bad)?Sometimes

Indicators for Moisturizing (Cooling) Herbs:

Please select any of the following that apply:
	Yes	No
Do you have vaginal dryness?	Do you have vaginal dryness?Yes	Do you have vaginal dryness?No
Have you experienced hot flashes recently?	Have you experienced hot flashes recently?Yes	Have you experienced hot flashes recently?No
Have you experienced nightsweats recently?	Have you experienced nightsweats recently?Yes	Have you experienced nightsweats recently?No
Do you have any type of dry infection (without vaginal discharge)?	Do you have any type of dry infection (without vaginal discharge)?Yes	Do you have any type of dry infection (without vaginal discharge)?No
Is the weather currently very hot?	Is the weather currently very hot?Yes	Is the weather currently very hot?No
Do you have an aversion to heat?	Do you have an aversion to heat?Yes	Do you have an aversion to heat?No
Do you radiate heat?	Do you radiate heat?Yes	Do you radiate heat?No

Do you have any food or plant allergies?

Do you have any food or plant allergies? No Yes, the following: Yes, the following:
Cloaking

When steaming it is often commonplace to wear a cloak or steam gown. Cloaking helps to increase the benefit of the treatment by enhancing the detoxification of the session. A couple notes of caution -first, it is not advised to use plastic as a cloak as it may release toxins when heated. Second, cloaking is not a good idea if you already have excess heat in your body. Let's check to see if you have any signs of excess heat.
Yes answers indicate excess heat in which case cloaking is not necessary. Instead use a towel,
light robe, steam gown, summer dress or light wrap-around fabric.

Please select any of the following that apply:
	Yes	No
Do you have hot flashes?	Do you have hot flashes?Yes	Do you have hot flashes?No
Do you have nightsweats?	Do you have nightsweats?Yes	Do you have nightsweats?No
Do you radiate heat?	Do you radiate heat?Yes	Do you radiate heat?No
Are you prone to infections or viruses?	Are you prone to infections or viruses?Yes	Are you prone to infections or viruses?No
Is it hot weather?	Is it hot weather?Yes	Is it hot weather?No
Do you have an aversion to heat?	Do you have an aversion to heat?Yes	Do you have an aversion to heat?No

No Periods
If you don't have periods, what is the reason?

If you don't have periods, what is the reason? Hysterectomy Pregnancy Postpartum Postmenopause Haven't had first period yet Depo-Provera birth control shot Oral birth control IUD I'm not sure why they are absent Other: Other:
Any other information you'd like me to know about you and/or your cycle?
Do you have any questions or hesitations prior to your vaginal steam session?
WAIVER

[PLEASE READ]

Most of the side-effects reported while steaming are positive. Users have reported better sleep and lucid dreams, relaxation, decreased swelling in legs and feet, decreased abdominal bloating, slimmer waistline, increased libido and sexual sensation; increased vaginal nectar and fertility, decrease in breast soreness, fewer headaches, fewer PMS symptoms and improved emotional balance, increased circulation and energy, tingling feet, glowing skin, reduction in incidence of hormonal acne and increased lubrication and vaginal nectar, scar softening, tighter vaginal canal and harmonization with the moon cycle.

WHAT TO EXPECT
Steaming is a cleanse. Some of the possible signs the vaginal steaming is working is if you experience -- the urge to urinate while steaming, brown discharge after steaming, increased clots or cramps during the period, increased dry cramps, increased irregular vaginal discharge (white, green, thick, clumpy), emotional release, periods that come earlier or later than expected. All of these signs are a normal part of the cleansing process and these signs will go away once the cleanse is complete. Please note these changes and let your practitioner know of these
positive changes.

BEST PRACTICES
1) Go to the bathroom directly prior to vaginal steaming.
2) Learn proper period care. Avoid tampon use and instead use cotton pads or period panties. The period is a uterine cleanse and if you support it the clots can easily clear out. Plugging up with tampons, on the other hand, prevents the old residue from clearing out and that is often the cause of cramping. It's also important to rest during the period and to eat the right foods. For more information about proper period care please take the course -- Moon Medicine: Radical Self-Care Practices for the Perfect Period -- available on the Steamy Chick website.
3) Increased vaginal discharge can be addressed by using cotton underwear liners and a peribottle throughout the day to clean mucus off the skin.

CAUTION SIGNS
If steaming causes a rash, bumps, headaches itchiness, diarrhea or the onset of fresh spotting or inter-period bleeding, this could be a sign that your steam protocol or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur please let your practitioner know so they can adjust the steam session as necessary or make a referral.
****
In 99% of all cases using a mild steam session and mild herbs will prevent any of the above signs from happening so it's very important that you give honest answers in this intake form so that the practitioner can set up a steam session that will fit your needs.

I understand that vaginal steaming may have positive or negative side effects as a result of doing a vaginal steam session. I accept legal responsibility for my choice to do a vaginal steam session and waive the responsibility of the practitioner and the facility where the steam session takes place in the case that any of the named side effects (or others) may occur.

My printed name and date below represent my signature.
Client Name (Signature) Client Name (Signature) First Last
Communication:
How would you like to hear back about your personalized steam plan?

How would you like to hear back about your personalized steam plan? Email Phone Other: Other:
Service Selection:
Steam Plan & Customized Herb Service Options
Optional Add-On Services

Optional Add-On Services Steam Chair: +$50 Steam Chair with Electric Burner Heat Source: +$60 Make my first steam an in-home visit - includes in-person steam setup instructions and guidance during your first steam. Please set aside 45-60 minutes for this visit. If this is your first postpartum steam, please have someone available to tend to your newborn, or I am also happy to hold your baby while you steam, if you feel comfortable with that arrangement: +$100 Complete Postpartum Sealing Package - includes gentle womb massage, rebozo bone closing, postpartum belly binding, and vaginal steam setup & guidance during your first steam. Please set aside 2 hours for this visit, so you do not feel rushed, have time to break to feed your baby if necessary, etc. Please have someone available to help tend to your newborn: +$200 Discounted Placenta Encapsulation Add-On for Complete Postpartum Sealing Package +$200. Please fill out the Placenta Encapsulation Agreement that is emailed to you after the submission of this form. The discounted rate of $200 for placenta encapsulation is for placenta capsules only (all other placenta add-on services are at cost). This deal can only be added to the Complete Postpartum Sealing Package.
Obtaining Herbs:
1. You may pick up your herbs from Courtney's home in Ocean Beach, CA - address will be given once order is placed.
2. Courtney will mail your herbs to you at a flat-rate of $4 per order.

1. You may pick up your herbs from Courtney's home in Ocean Beach, CA - address will be given once order is placed.
2. Courtney will mail your herbs to you at a flat-rate of $4 per order. I will pick up my herbs. Please mail my herbs: +$4
If you have ordered a steam chair and would like it mailed, you will be charged an additional shipping fee at the current, most affordable rate through the USPS. Courtney will give you this updated rate after receiving your intake.

If you have ordered a steam chair and would like it mailed, you will be charged an additional shipping fee at the current, most affordable rate through the USPS. Courtney will give you this updated rate after receiving your intake. Agree
Processing Time:
It may take up to one week to receive your steam plan, herbs and/or steam chair, especially if you are requesting your herbs and/or steam chair by mail. As a birth worker, I am sometimes called to births, which makes my schedule a little unpredictable. I will always do my best to get your products to you ASAP. Please do not hesitate to reach out if you ever have any questions or concerns. I'm here to help :)

It may take up to one week to receive your steam plan, herbs and/or steam chair, especially if you are requesting your herbs and/or steam chair by mail. As a birth worker, I am sometimes called to births, which makes my schedule a little unpredictable. I will always do my best to get your products to you ASAP. Please do not hesitate to reach out if you ever have any questions or concerns. I'm here to help :) Agree
Payment
Payment is due in full upon submission of this agreement before you will receive your steam plan and herbs.

Payment is due in full upon submission of this agreement before you will receive your steam plan and herbs. Agree
You may make your payment in one of the following ways:
- Mail a check made out to ‘Courtney Scott' to 4741 Brighton Ave, San Diego, CA 92107.
- Send payment through PayPal directly to my email (Courtney@mysandiegodoula.com) via the ‘send to friends/family’ option.
- You may send payment through Venmo. My Venmo username is @CourtneyScottDoula.
- You may send a payment through ApplePay to my cell 619-618-8587.

You may make your payment in one of the following ways:
- Mail a check made out to ‘Courtney Scott' to 4741 Brighton Ave, San Diego, CA 92107.
- Send payment through PayPal directly to my email (Courtney@mysandiegodoula.com) via the ‘send to friends/family’ option.
- You may send payment through Venmo. My Venmo username is @CourtneyScottDoula.
- You may send a payment through ApplePay to my cell 619-618-8587. Agree
Once herbs are shipped and received, no returns, exchanges or refunds will be given.

Once herbs are shipped and received, no returns, exchanges or refunds will be given. Agree

Vaginal Steam Intake

Vaginal Steam Intake

How to answer the questions on this Intake...

Contraindications

Hard Contraindications

Soft Contraindications

Sensitivities

Period Symptoms

Herb Selection

Indicators for Cleansing Herbs:

Indicators for Gentle Herbs:

Indicators for Disinfecting Herbs:

Indicators for Moisturizing (Cooling) Herbs:

Cloaking

No Periods

WAIVER

Communication:

Service Selection:

Obtaining Herbs:

Processing Time:

Payment