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Home
About Us
Services
Body Care
Blood Type Protocol
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Contact Us
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Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Wellness Services
Spa Packages
Contact Us
Specials
Gift Certificates
Client Form
Policies and Procedures
Events
Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Wellness Services
Spa Packages
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Total Body Wellness
Wellness Services
Contact Us
Specials
Gift Certificates
Client Form
Policies and Procedures
Events
X
Gift Certificates
Client Form
Policies and Procedures
Events
Gift Certificates
Client Form
Policies and Procedures
Events
Home
About Us
Services
Body Care
Blood Type Protocol
Massage Therapy
Skin Care
Total Body Wellness
Wellness Services
Contact Us
Specials
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VAGINAL STEAM INTAKE FORM
Name
*
Date of Birth
*
Phone
*
Email
*
Please fill in all information below. All information is kept strictly confidential. Do you now or have you ever had the following:CONTRAINDICATIONS FOR CURRENT CONDITIONS
Are you currently on your period?
*
YES
NO
YEAR DIAGNOSED
*
Do you currently have fresh spotting?
*
YES
NO
YEAR DIAGNOSED
*
Have you had spontaneous heavy bleeding within the past 3 months?
*
YES
NO
YEAR DIAGNOSED
*
Have you had two periods per month (i.e. a period every 2 weeks) in the past 3 months?
*
YES
NO
YEAR DIAGNOSED
*
Are you pregnant?
*
YES
NO
YEAR DIAGNOSED
*
If trying to conceive are you past ovulation or IUI/ IVF
*
YES
NO
YEAR DIAGNOSED
*
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*If yes to any of the above, that indicates that vaginal steaming is contraindicated. It is not safe and could result in bleeding or a miscarriage.
Do you have an infection characterized with a burning itch?
*
YES
NO
YEAR DIAGNOSED
*
Do you have tubal coagulation (burning of the fallopian tube through laparoscopic surgery through the belly button)?
*
YES
NO
YEAR DIAGNOSED
*
Do you have a birth control arm implant (i.e. Nexplanon)?
*
YES
NO
YEAR DIAGNOSED
*
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?
*
YES
NO
YEAR DIAGNOSED
*
Do you have an Essure insert?
*
YES
NO
YEAR DIAGNOSED
*
Do you currently have the Nuva Ring inserted? (If so, it should be removed prior to steam session.)
*
YES
NO
YEAR DIAGNOSED
*
Is this your first time doing a steam session?
*
YES
NO
YEAR DIAGNOSED
*
Are your menstrual cycles currently or historically every 27 days or shorter?
*
YES
NO
YEAR DIAGNOSED
*
Have you experienced any hot flashes over the past month?
*
YES
NO
YEAR DIAGNOSED
*
Have you experienced any night sweats over the past month?
*
YES
NO
YEAR DIAGNOSED
*
Do you have an IUD in?
*
YES
NO
YEAR DIAGNOSED
*
Are you currently or historically prone to yeast infections?
*
YES
NO
YEAR DIAGNOSED
*
Are you currently or historically prone to bacterial vaginosis?
*
YES
NO
YEAR DIAGNOSED
*
*If you are using any of the above birth control methods, vaginal steaming could cause a birth control failure. It is NOT recommended unless you are okay with a backup form of birth control or you are not concerned about a possible pregnancy. *If you have had a uterine ablation procedure to scar over the uterine walls it is possible that vaginal steaming will clear the scar tissue reversing the surgery. OTHER HEALTH CONCERNS
Do you have herpes?
*
YES
NO
YEAR DIAGNOSED
*
Do you have vaginal dryness?
*
YES
NO
YEAR DIAGNOSED
*
Hysterectomy
*
YES
NO
YEAR DIAGNOSED
*
Postpartum
*
YES
NO
YEAR DIAGNOSED
*
Any other health concerns not mentioned?
*
Any Food or Plant Allergies? Please list below.
*
Notes
My signature indicates that I am requesting this service on my own initiative and acknowledge that the therapist and Main Street Spa & Wellness Center do not diagnose ailments or prescribe treatments. I release Main Street Spa & Wellness Center and their staff from liability for claims arising from the use of vaginal steaming. We reserve the right to restrict or refuse any client.
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