Yoni Steam Intake Form | WombmenThings

Name *

First

Last

Address *

City / State / Zip: *

Phone Number *

Email *

Comment or Message *

Occupation

Date of Birth *

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? *

Yes
No

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?

(an abnormal absence of menstruation.)

Do you have any concerns about your menstrual cycle? *

A.R.T. Assisted Reproductive Technology

Are you under treatment for Infertility? *

Yes
No

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

Describe past treatments:

Pregnancy History

Are you pregnant or trying to conceive? *

Yes
No

How many pregnancies have you had? Number of Deliveries *

Terminations | When?

Miscarriages | When?

Complications

Deliveries:

Birth date | Infant name | Gender | Complications

Please check all that applies: *

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 (fill in your full name) 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 Journey to Calm llc, and/or Nonika Brown any liability.

Vaginal Steam Bath Intake Form