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Let’s Talk Yoni and Wellness Care

 

 

Please print and fill out completely before your Yoni steam appointment

 

First and Last* _____________________________________________________

 

E-mail: * ___________________________________________________________

 

(Area Code) Phone Number: * _____________________________________ 

 

Date of Birth* ______________________________________

 

  1. Are you currently pregnant? * YES/NO 

 

  1. Is there a chance that you might be pregnant? * YES/NO/NOT SURE

 

How did you hear about Feminine Mystique Wellness Spa? *

 

____________________________________________________________

  1. Have you ever had a vaginal steam before? * YES/ NO

 

  1. Where are you in the life stage of your cycle?

SELECT OPTIONS

  • CYCLE NOT YET STARTED

  • MONTHLY MENSTRUAL

  • MENOPAUSE

  • PERIMENOPAUSE

  • FULL HYSTERECTOMY

  • POSTPARTUM

 

  1. Are there any herbs that you are allergic to? Please list them here or simply put "none" if you have no allergies.

__________________________________________________________

  1. Do you suffer from menstrual cramps? If so, please select all that apply.*

SELECT OPTIONS

  • CRAMPS AT OVULATION

  • CRAMPS PRIOR TO FLOW

  • CRAMPS DURING FLOW

  • NO CRAMPS

  • POSTPARTUM

  • NOT BLEEDING

  • OTHERS

 

  1. Color of blood, please select all that apply.*

SELECT OPTIONS

  • NO LONGER BLEEDING                       

  • BROWN BLOOD AT END OF FLOW           

  • RED ONLY                                       

  • BROWN SPOTTING DURING MONTH

  • BROWN BLOOD                                           

  • POSTPARTUM NOT BLEEDING YET

  • BLACK  BLOOD                                         

  • BROWN BLOOD AT START OF FLOW

  • PINK AND RED ONLY                   

  • CLOTS DURING FLOW

  • STRINGY BLOOD

 

  1. Type of flow*, please select all that apply.*

SECLECT OPTIONS

  • LIGHT FLOW                       

  • MEDIUM FLOW 

  • HEAVY FLOW                     

  • VERY HEAVY FLOW

  • NO LONGER BLEEDING     

  • POSTPARTUM NOT BLEEDING YET

 

If applicable, when was your last most recent menstrual bleed. If not applicable, please put n/a*

 

___________________________________________________________

 

 

 

  1. Please indicate the length of your typical monthly cycle. Your monthly cycle is how long it is from the

first day of a bleed to the day before your next bleed. *

SELECT OPTIONS

  • VARYING MONTHLY CYCLE LENGTH

  • 21 DAYS MONTHLY CYCLE OR LESS

  • 22-23 DAY MONTHLY CYCLE

  • 24-25 DAY MONTHLY CYCLE

  • 26-27 DAY MONTHLY CYCLE

  • 28-30 DAY MONTHLY CYCLE

  • 31 DAY MONTHLY CYCLE

  • DON’T KNOW MY MONTHLY CYCLE

 

If you selected varying cycle length or don't know my cycle length or bleed length, please expand/describe. Include approximate shortest and longest cycle length.

____________________________________________________

 

 

  1. Do you have skipped bleeds or suffer from Amenorrhea? * YES / NO

 

 

  1. Menstrual products currently being used; select all that apply*

SELECT OPTIONS

  • NO LONGER BLEED             

  • CLOTH MENSTRUAL PADS

  • DISPOSABLE PADS               

  • DIVA CUP/ MENSTRUAL CUP

  • TAMPONS                              

  • OTHER _________________________________________

 

  1. Do you currently experience any of the following symptoms during your monthly cycle? Please select all that apply*

SELECT OPTIONS

  • HOT FLASHES                         

  • SWOLLEN FEET     

  • NIGHT FLASHES                 

  • PMS

  • ABDOMINAL BLOATING     

  • CONSTIPATION       

  • TENDER BREAST                 

  • MOOD SWINGS

  1. Current Birth Control Method.*

SELECT OPTIONS

  • NONE               

  • CONDOMS

  • NEXPLANON

  • MIRENA         

  • ABSTINENCE

  • THE PILL  

  • OTHER

 

  1. Please indicate the typical length of only your bleeding days. *

SELECT OPTIONS

  • NO LONGER BLEED           

  • 6-8 DAYS

  • LESS THAN 4 DAYS             

  • 8-10 DAYS

  • 4 DAYS ON AVERAGE         

  • BLEED LENGTH VARIES MONTHLY

  • 4-6 DAYS                               

  • POSTPARTUM NOT BLEEDING YET

 

  1. Regarding vaginal discharge/fluid please select all that apply. *

SELECT OPTIONS

 

  • WHITISH                       

  • FEMININE ODOR

  • YELLOWISH                 

  • CLEAR

  • GREENISH                   

  • BLOOD TINGED

  • NONE OF THE ABOVE 

 

  1. Any health conditions that will prevent you from steaming?* YES / NO ____________________

 

 

1. Please check all physical conditions that you are currently experiencing.

SELECT OPTIONS

  • PCOS                                             

  • SCAR TISSUE                             

  • LOW LIBIDO

  • ENDOMETRIOSIS                       

  • UTERINE CANCER                   

  • UTI

  • CYSTS                                           

  • OVARIAN CANCER                 

  • ABNORMAL PAP SMEAR

  • FIBROIDS                                   

  • UTERINE PROLAPSE               

  • CERVICAL DYSPEPSIA               

  • STD                                               

  • BIRTH TRAUMA                      

  • PAINFUL INTERCOURSE

  • NONE OF THE ABOVE                   

  • OTHER

  1. Please check any of the following conditions that you experience on a regular basis, although perhaps not currently. 

SELECT OPTIONS

  • YEAST INFECTION/ CANDIDA                   

  • DIARRHEA                             

  • FREQUENT UTI’S                                       

  • CONSTIPATION

  • FUNGAL INFECTION       

  • BV (Bacterial vaginosis)     

  • NONE OF THE ABOVE                              

 

Do you wish to expand on anything or is there anything else important that you feel we should know? If so, please use the space provided below.

___________________________________________________________

1. Do you have any questions or concerns before we begin your personal vaginal steam plan?YES / NO

____________________________________________________________

 

 

What do you hope to accomplish through vaginal steaming?

 

 

____________________________________________________________

 

 

 

If you said yes to any of the following below, you fall under our mild steam for sensitive goddesses.

  • Short menstrual cycles​ ( 27 days or shorter) ​

  • Hot flashes/ Night sweats​

  • Prone to infections​

  • Herpes/STDs​

  • IUD (Do not steam with a plastic IUD)​​

  • NUVAring (remove nuvaring before steaming)

  • Hormonal birth control 

  • Depovera Shot

  • Viruses

  • High blood pressure

  • Breastfeeding

  • Bladder infection

we will start the first treatment with a 10-minute session, and increase time on subsequent sessions based on your comfort level, irritation level and observation by a certified yoni practitioner.

  • When to avoid Vaginal Steaming; If you are pregnant or there is a possibility of pregnancy. During or after ovulation if you are trying to conceive. During Menstruation. If you have had heavy spontaneous bleeding mid-cycle within the last three months, it is not recommended to do a vaginal steam. It is not recommended to steam after laser hair removal. We recommend waiting 1 weeks after laser hair removal. Please note that piercings will need to be removed to avoid burns.

I understand    YES / NO

  • IUD Precautions; Steaming is considered safe with a copper IUD, a plastic intrauterine contraceptive device including coil, loop, triangle or T shape made of anything other than copper.) * SENSITIVE BLENDS ONLY - MILD & GENTLE

I understand    YES / NO

  • Steaming should not be done when the body is fighting an illness such as the flu or any other fevered condition. When the body is fighting an active infection, resting is a priority over steaming. It is important that you listen to your body first and foremost over all guidelines. You should stop your steam if you feel any of the following; generally unwell, lightheaded, dizzy, nauseous, intense headache, short of breath or if your body tells you so, trust your instincts. *

I understand    YES / NO

  • Burn risk; Just like drinking a hot beverage like tea or coffee there is a chance to burn yourself if you do not first test the temperature by placing a sensitive part of your body, like the inside of your elbow, over your box. *

I understand and agree to test the temperature to make sure it is suitable for me before I steam

                           YES / NO

 

  • I certify that I am above the age of 18 years old. *   

                           YES / NO

 

  • LIABILITY AGREEMENT; I certify that the above information is true and complete, to the best of my knowledge. I fully understand that I am solely responsible for my health, safety and well-being while vaginal steaming. I understand that the use of drugs, medication or alcohol prior to or during the vaginal steam session may lead to dizziness or unconsciousness. I will discontinue the use of the vaginal steam immediately if I feel light-headed, dizzy, heat exhausted, feel unwell or my body or intuition tells me to do so. I understand I should drink plenty of water before and after a vaginal steam session. I understand that there are risks associated with any health treatment including vaginal steaming. While every precaution shall be taken to ensure the good welfare during a steam session or in the preparation of herbs or a personal steam plan, Feminine Mystique Wellness Spa, employees, volunteers, are hereby released from any liability in the event of any accident or misfortune that may occur from the result of vaginal steaming.*

I have read and agree to the Liability Agreement*

                           YES / NO

 

 

 

Client Signature:____________________________________________      Date:_________________________

Thank you. We will see you soon!

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