Name * First Name Last Name Email * STEAM PLAN Steam Indication 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 Soft Contraindication to Discuss Further Only a Herbal Bath is Recommended Wait to Steam See Referral AYURVEDIC PRACTITIONER NOTES STEAM SENSITIVITIES Uterine Bleeding Sensitivity Medical Sensitivity Heat Sensitivity Age Sensitivity First Timer STEAM SETUP No Heater Setup Heater Setup STEAM DURATION 10 Minutes 30 Minutes 45 Minutes CLOAK Yes No STEAM HERB FORMULA Hemostatic Cooling Disinfecting Cleansing Salt (½ tsp. per 6 cups water/1.5 quarts/1.5 litres) No herbs - Water Only STEAM SCHEDULE RECOMMENDATION Weekly 3 days in a row before period + 3 days in a row after period REFERALS Peristeam Hydrotherapist Ayurvedic Doctor / Practitioner Acupunturist Medical Doctor Midwife Therapist or Healaer Pelvic Floor Physical Therapist Abdominal Massage Practitioner Other REFERRAL NOTES AND CONTACT INFO STEAM RESOURCES PRACTITIONER NOTES Thank you!
