Yoni Steaming — Breathe Birth Care

Client Name

First Name

Last Name

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Address

Address 1

Address 2

City

State/Province

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Date of Birth

YYYY

Current Date

YYYY

Contraindications

There are times when it is not beneficial for a woman to steam. As a first step, let's check and make sure that you are safe to steam.

Please Mark Any of the Following Hard Contraindications that Apply

Are you currently on your period?

Yes

Not Sure

Do you currently have any fresh spotting?

Yes

Not sure

Have you had spontaneous heavy bleeding within the past 3 months?

Yes

Not Sure

Have you had two periods per month (i.e. a period every 2 weeks) in the past 3 months?

Yes

Not Sure

Are you pregnant?

Yes

Not Sure

Is there a possibility you are pregnant?

Yes

Not Sure

If trying to conceive are you past ovulation or IUI/IVF transfer?

Yes

Not Sure

Please Provide Further Information for Responses that are "Yes" or "Not Sure"

IMPORTANT The above "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 Mark Any of the Following Soft Contraindications that Apply

Do you have an infection characterized with a burning itch?

Yes

Not Sure

Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?

Yes

Not Sure

Do you have a birth control arm implant (i.e. nexplanon)?

Yes

Not Sure

Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?

Yes

Not Sure

Do you have an Essure insert?

Yes

Not Sure

Please Provide Further Information for Responses that are "Yes" or "Not Sure"

IMPORTANT

If you are using the above birth control methods it may be possible that vaginal steaming could cause a birth control failure. Steaming is not recommended unless you are okay with using a backup form of birth control or you are not concerned about your birth control failing. If you have a burning itch the warmth from the steam could be uncomfortable since there is already so much heat in your body. In this case you could try doing a sitz bath with cooling herbs. It is also recommended to seek treatment from an acupuncturist to address the underlying imbalances causing the burning itch. Once the burning itch subsides you may proceed with a vaginal steam. If you have had a uterine ablation procedure (to scar over the uterine walls) it may be possible that vaginal steaming will clear the scar tissue which would reverse the surgery. If you are okay with reversing the surgery then feel free to proceed with a vaginal steam.

Steam Sensitivites

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 suits you. Let's see if you have any sensitivities.

Please Mark All That Apply

Is this your first time doing a steam session?

Yes

Not Sure

Are your menstrual cycles currently or historically ever 27 days or shorter?

Yes

Not Sure

Have you experienced any hot flashes over the past month?

Yes

Not Sure

Have you experienced any night sweats over the past month?

Yes

Not Sure

Do you have an IUD in?

Yes

Not Sure

Are you currently or historically prone to yeast infections?

Yes

Not Sure

Are you currently or historically prone to bacterial vaginosis?

Yes

Not Sure

Are you currently or historically prone to urinary tract infections (bladder infections)?

Yes

Not Sure

Do you have herpes?

Yes

Not Sure

Do you have the nuva ring in? (If so, it should be removed prior to steam session)

Yes

Not Sure

Are you age 13 or younger?

Yes

Not Sure

Do you have a history of spontaneous bleeding or two periods per month (3 months or later in the past)?

Yes

Not Sure

Please Provide Further Information for Responses that are "Yes" or "Not Sure"

The above "yes" replies indicate steam sensitivity in which case a mild 10 min setup without an electric burner should be used. Under no circumstances should clients who have sensitivity use an advanced setup with an electric burner.

No Periods

Herb Selection

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

Indicators for a Cleansing Herb Formula

Are your menstrual cycles 28 days or longer?

Yes

Are your menstrual cycles 28 days or longer? Is your menstrual cycle absent or missing for an unknown reason or because of birth control?

Yes

Are you currently taking birth control pills?

Yes

Indicators for a Gentle Herb Formula

Do you ever have menstrual cycles 27 days or less?

Yes

Do you have fresh spotting between periods?

Yes

Are you currently underage 13?

Yes

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

Indicators for a Disinfecting Herb Formula

Do you have a green vaginal discharge?

Yes

Sometimes

Do you have yellow vaginal discharge?

Yes

Sometimes

Do you have white vaginal discharge?

Yes

Sometimes

Do you have thick vaginal discharge

Yes

Sometimes

Do you have malodorous vaginal discharge?

Yes

Sometimes

Indicators for a Cooling Herb Formula

Do you have vaginal dryness?

Yes

Have you experienced hot flashes recently?

Yes

Have you experienced night sweats recently?

Yes

Do you have any type of dry vaginal infection (without vaginal discharge)?

Yes

Is the weather currently very hot?

Yes

Do you have an aversion to heat?

Yes

Do you radiate heat?

Yes

Do You Have Any Food or Plant Allergies?

Cloaking

When steaming it is often commonplace to wear a cloak to make the entire body sweat and thereby enhance the detoxification of the steam session. A cloak is often a blanket put over the entire body or a thick robe. Cloaking is not recommended if the body already has excess heat. Let's check to see if you have any signs of excess heat.

Mark All Excess Heat Indicators that Apply

Hot Flashes

Night Sweats

Radiate Heat

Prone to Vaginal Infections or Viruses

Hot Weather

Aversion to Heat

Please Provide Further Information for Any Checked Responses

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.

What to Expect

Steaming is a cleanse. Some of the possible signs the vaginal steaming is working is if you experience the following: urination urge while steaming, brown discharge after steaming, increased clots or cramps during the next 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 should go away once the cleanse is complete. Please note these changes and inform your practitoner.

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 ask your practitioner or take the course -- Womb Cleanse Care -- available on the Steamy Chick website. 3) Increased vaginal discharge can be addressed by using cotton underwear liners and a peri-bottle 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 plan 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 most cases, using a mild steam session and custom 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.

INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

Below is a legal waiver between the practitioner and the client stating that the client will not sue the practitioner in the event that something undesired occurs. Filling out this waiver is required to receive products or services from the practitioner.

Client Name

First Name

Last Name

THIS AGREEMENT is made between Practitioner Name and Company (as indicated in the practitioner section), Keli Garza, Chick Food Inc (“Company”) and Client (as typed in the field above) ("I") (collectively the “Parties”). I have purchased or am receiving complimentary steaming services, products or a consultation from Company (the "Products and/or Services"). I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in, or cause me to have an adverse reaction to, the Services, including but not limited to preterm pregnancy. I affirm that I have reviewed the “Best Practices” and other information provided to me by Company or its agents. I further affirm, that all information provided to Company by me is accurate and complete and I understand that failing to provide information may result in a greater risk of injury. I acknowledge that my purchase and participation in or use of the Products and/or Services is voluntary and I do so entirely at my own risk. I acknowledge that I have approval from my doctor or medical professional to use or receive the Products and/or Services or I yield that requirement and take responsibility for my own medical decision-making. I understand that results may vary from person to person. I understand that I may react adversely to the Products and/or Services and they may result in injury to me. Side effects include, but are not limited to, rash, bumps, headaches, itchiness, diarrhea, increased vaginal discharge, cramping or the onset of fresh spotting or inter-period bleeding. If I elect to continue Products and/or Services after such results, I will alert Company to issues so that the Products and/or Services may be adjusted, or a referral can be made. I expressly agree that all risk of injury that I undertake as a part of the Products and/or Services is undertaken at my sole risk. I further expressly agree that I will not use any equipment related to the Products and/or Services improperly. If equipment is located on the Company premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release Company, its agents and employees from any claim, demands, injuries, damages, actions, or causes of action, that could occur from my inappropriate use of such equipment. I affirm that I have confirmed on www.steamychick.com that Company’s practitioner has a vaginal steam specialist certification. I also understand and agree that all information provided before, during, or after the Products and/or Services is for informational purposes only and is not a replacement for medical advice from a physician or pediatrician. The Products and/or Services and information provided therein does not replace the relationship between physician/therapist and a client in a one-on-one treatment session with an individualized treatment plan based on their professional evaluation. The Products and/or Services and any information therein are provided "as is" without any representations or warranties, express or implied. I will not rely on the Products and/or Services as an alternative to advice from my medical professional or healthcare provider and I will never delay seeking medical advice, disregard medical advice, or discontinue medical treatment as a result of any information provided before, during, or after the Products and/or Services. I understand and agree that all medical related information is for informational purposes only. Company, its agents and employees, shall not be liable to me for any claims, demands, injuries, damages, actions or causes of action to my person or property arising out of or connected with the Products and/or Services and the premises where the Products and/or Services are located. I expressly release Company, its agents and employees from all such claims, demands, injuries, damages, actions, or causes of action, and from all acts of active or passive negligence on the part of Company, to the extent such a release of negligence is permissible by law. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during the Products and/or Services. In the event of sickness, accident, or injury, I authorize Company and its representatives to obtain, on my behalf, emergency medical treatment at my expense. This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. This Agreement shall be construed and enforced according to the laws of the State of California and any dispute under this Agreement must be brought in this venue and no other. I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I UNDERSTAND AND AGREE THAT I AM GIVING UP LEGAL RIGHTS BY SIGNING THIS AGREEMENT AND THAT I AM DOING SO VOLUNTARILY, FREELY, UNDER NO THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE, OR GUARANTEE BEING COMMUNICATED TO ME. THE SIGNATURE BELOW IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW. My printed name and date below represent my signature.

Client Name (signature)

First Name

Last Name

Date of Signature

YYYY

Yoni Steaming Intake Form

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