Peristeam Facilitator Intake Form

Provided by the Peristeam Hydrotherapy Institute by Steamy Chick This intake form does not apply if someone is postpartum (0-12 months) or for pregnancy loss (if the period has not yet returned For steam plans regarding these situations please seek a consultation with a Peristeam Hydrotherapist.

example@example.com Phone Number (optional) Please enter a valid phone number. Address (optional)

Your Practitioner's Contact Details

Please enter the name and email of the practitioner who sent you this form.

Which of the following is a reproductive organ you were born with?.

Has your genitalia anatomy altered at all since birth due to voluntary or medical surgery or alterations?

Have you experienced hot flashes recently?

Have you experienced nightsweats recently?

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

Is the weather currently very hot?

Do you have an aversion to heat?

Indicators for a 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 a Cleansing Herb Formula

Are your menstrual cycles 28 days or longer?

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

Are you currently taking birth control pills?

Do you have any known or suspected plant or food allergies?

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

Are you prone to genital infections or viruses?

Do you have an aversion to heat?

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 or unexpected occurs. Filling out this waiver is required to receive products or services from the practitioner.

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

Uterine Bleeding Contraindications

Are you currently on your period or experiencing fresh ongoing bleeding?

Have you had fresh spotting with the past 24 hours?

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

c Have you had 2 periods per month (i.e a period every 19 days or less) within the past 3 months?

Is there a possibility you are pregnant?

If receiving fertility assistance, are you past ovulation or IUI/IVF transfer?

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

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

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

Are you within 6 weeks post-surgery?

Have you had a uterine fibroid embolization procedure?

Do you have a genital or rectal infection characterized with a burning sensation?

Some people 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.

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

Do you have a history of spontaneous bleeding or 2 periods per month (3 months ago or later in c the past)?

Have you experienced any hot flashes over the past month?

Have you experienced any nightsweats over the past month?

Are you currently or historically prone to yeast infections?

Are you currently or historically prone to bacterial vaginosis?

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

Do you have active or dormant herpes?

Is this your first time doing a steam session?

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

Uterine Bleeding Contraindications

Are you currently on your period or experiencing fresh ongoing bleeding?

Have you had fresh spotting with the past 24 hours?

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

Have you had 2 periods per month (i.e a period every 19 days or less) within the past 3 months?

Is there a possibility you are pregnant?

If receiving fertility assistance, are you past ovulation or IUI/IVF transfer?

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

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

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

Are you within 6 weeks post-surgery?

Have you had a uterine fibroid embolization procedure?

Do you have a genital or rectal infection characterized with a burning sensation?

Some people 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.

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

Do you have a history of spontaneous bleeding or 2 periods per month (3 months ago or later in the past)?

Have you experienced any hot flashes over the past month?

Have you experienced any nightsweats over the past month?

Are you currently or historically prone to yeast infections?

Are you currently or historically prone to bacterial vaginosis?

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

Do you have active or dormant herpes?

Is this your first time doing a steam session?

If you don't have periods what is the reason?

I'm not sure -- they are absen

I am a Non-Menstruator (born without uterus)Other Please provide further information.

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

Indicators for a Hemostatic Herb Formula

Do you ever have menstrual cycles 27 days or less?

In the past month did you have any fresh spotting menstrual cycle day 27 or earlier?

Have you had ongoing bleeding (bleeding that lasts 10 days or longer of fresh blood) in the past c 3 months?

Do you have a history of spontancous bleeding or 2 periods per month?

Are you 12 years of age or younger?

Indicators for a Cooling Herb Formula