DATE

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CLIENT NAME *

First Name

Last Name

PHONE *

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ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DATE OF BIRTH

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DD

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Client Info *

From a medical perspective what type of anatomy were you born with?

Male

Female

HARD CONTRAINDICATIONS

UTERINE BLEEDING CONTRAINDICATIONS Your safety and well-being are our top priorities. While vaginal steaming offers numerous benefits, it's essential to ensure that it's appropriate for you. Certain medical conditions or circumstances may make steaming unsafe or less effective. Before scheduling a steam session, we conduct a thorough assessment to determine if it's suitable for you.

Are you currently menstruating or experiencing ongoing bleeding

Have you noticed any recent spotting within the last 24 hours?

Have you experienced any episodes of spontaneous heavy bleeding in the past 3 months?

Have you had two periods per month (for example, a period every 19 days or less) within the past 3 months?

PREGANANCY CONTRAINDICATIONS

Are you pregnant?

Is there a possibility that you are pregnant?

If you have received fertility treatment such as IUI/IFV, are you past ovulation?

SOFT CONTRAINIDICATIONS

MEDICAL CONTRAINDICTAIONS

Have you undergone tubal coagulation, involving the burning of the fallopian tubes through laparoscopic surgery performed through the belly button?

Do you currently have a birth control implant or patch (such as Nexplanon)

Have you undergone a uterine ablation procedure, where the uterine walls are burned to induce scarring?

Do you have Essure insert?

Are you within 6 weeks post surgery?

Have you had a procedure called uterine fibroid embolization, which is a minimally invasive treatment for uterine fibroids?

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HEAT CONTRAINDICATIONS

Do you have any active genital or rectal infection that has a burning sensation?

Do you have any heat or itchy sensations in the vagina region?

STEAM SENSITIVITIES

UTERINE BLEEDING SENSITIVITY Some individuals may be highly responsive to steam, eliciting a physiological reaction. If you fall into this category, it's perfectly fine to proceed with steaming. However, your Ayurvedic practitioner will customize your steam session and herbal blend to align with your Ayurvedic constitution. Let's assess for any sensitivities before proceeding

Do your menstrual cycles currently or historically last 27 days or less?

Do you have a history of experiencing spontaneous bleeding, such as having two or more periods per month, within the past 3 months or later?

MEDICAL SENSIVITY

Do you have an IUD?

Do you have a Nuva Ring in?

HEAT SENSITIVITY

Have you experienced hot flashes in the past month?

Have you experienced night sweats in the past month?

Are you prone to yeast infections (either currently or in the past)?

Are you prone to bacterial vaginosis (either currently or in the past)?

Are you prone to urinary tract infections/bladder infections (either currently or in the past)?

Do you have active or dormant herpes?

AGE SENSITIVITY

Are you 13 years or younger?

Are you not sure of your age?

FIRST TIMER

Is this your first steam session?

Have you steamed before or done any Yoni therapies?

NO PERIODS If you don't have periods, please indicate the reasons?

Hysterectomy

Pregnancy

Postpartum

Postmenopuase

Haven't had first period yet

Birth Control

IUD

Not sure -- they are absent

I am a Non-Menstruator

Other

HERB SELECTION

INDICATORS FOR HEMOSTATIC HERB FORMULA

Do you have menstrual cycles 27 days or less?

In the past month did you have fresh spotting on day 27 or earlier?

Have you had ongoing bleeding (bleeding lasting more than 10 days or longer of fresh blood) in the past 3 months?

Are you 12 years old or younger?

INDICATORS FOR COOLING HERB FORMULA

Do you have vaginal dryness?

Have you experienced hot flashes recebtly?

Have you experienced night-sweats recently?

Do you have dry genital infection (without discharge)?

Is the weather currently very hot?

Do you radiate heat?

INDICATORS FOR DISINFECTING HERB FORMULA

Do you have green vaginal discharge?

Do you have yellow vaginal discharge?

Do you have white vaginal discharge?

Do you have thick vaginal discharge?

Do you have malodorous (bad smelling) vaginal discharge?

INDICATORS FOR CLEANSING HERB FORMULA

Are you menstrual cycles 28 days or longer?

Is your menstrual cycle absent or missing because of known or unknown reasons? Or are you a non-menstruator (born without uterus)?

Are you currently taking birth control pills?

CLOAKING

While steaming, it's common practice to use a cloak, such as a blanket or thick robe, to encourage sweating throughout the entire body and enhance detoxification. However, cloaking isn't suitable for everyone, especially those who are sensitive to heat. Let's assess your suitability for cloaking before proceeding. MARK ALL EXCESS HEAT INDICATORS THAT APPLY

Do you have hot flashes?

Do you have night-sweats?

Do you radiate heat?

Are you prone to genital infections or viruses?

Is the weather currently hot?

Do you have an aversion to heat?

Steaming can be highly effective in rejuvenating the reproductive health system when performed weekly for three to six months or until all issues are resolved. Menstruators are advised to complete a new intake form with their Peristeam facilitator after each menstrual cycle to assess if any adjustments to herbs or setup are needed, which is often the case. Which of the following options would you be interested in?

Monthly Steam Intakes

One Time Steam Intake Without Continued Monthly Intakes

Regular steaming sessions, both weekly and before and after menstruation, can significantly optimize health. Committing to this steaming schedule for 3 to 6 months can yield great results. It's also beneficial for menstruators to steam three times before and three times after their period. For more complex concerns or issues, an additional in-depth consultation with an Ayurvedic Practitioner may be helpful to develop a specific steam plan and herbal support tailored to your needs. To create the most effective steam plan for you, please indicate which of the following options you are interested in. You can select all that apply.

Weekly Steam Sessions

3 x before and 3 x after period

I would like to do an initial more in-depth Ayurvedic consultation for a specific issue and would be willing to steam daily or the recommendation.

Where do you plan to steam?

My own steam setup

I'd like a mobile steam practitioner to come to me

I'd like to go to a certified steam spa or office location

Do you need recommendations for any of the following

Purchase of Steam Sauna

Purchase of Steam Herbs

Purchase of Ayurvedic Herbs & Supplements

How to Make Steam Herbs

How to Setup at Home Without Steam Sauna

Local Steam Spa or Office

How to Find an Ayurvedic Practitioner and Yoni Facilitator for a consultation regarding advanced issues