Name * First Name Last Name Email * Preferred pronouns * Reason for visit When did your concerns first start? Has there been a medical diagnosis? Reproductive Health When was the first day of your last period? How often do your periods come & how many days do they last? Do you have concerns around your cycle? How do you feel about your cycle overall? Are you under fertility treatment? If so please describe Are you trying to conceive? Are you on birth control if so which type? How many pregnancies have you had? Have you experienced loss? How was your birth(s) if you've had one? Please check any that apply to you Abnormal pap Dark cycle at beginning or end of cycle PCOS Endometriosis Excessive bleeding Absent ovulation Low libido Cysts Polyps PMS STI's (HPV, Herpes,HIV) Infection (yeast/bacterial vaginosis) Vaginal dryness Hemorrhoids Mid cycle spotting Menopause IUD If needed, describe or give more detail from anything above 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 yoni steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a medical provider, or other qualified medical specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the 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. 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 statement above Please understand that though IUD's are not completely contraindicated that they can be at risk of being pushed out with a ongoing steam practice. I understand Thank you!
