YONI Health Intake form | Feminine Mystique WS

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* ______________________________________

Are you currently pregnant? * YES/NO

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

How did you hear about Feminine Mystique Wellness Spa? *

____________________________________________________________

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

Where are you in the life stage of your cycle?

SELECT OPTIONS

CYCLE NOT YET STARTED
MONTHLY MENSTRUAL
MENOPAUSE
PERIMENOPAUSE
FULL HYSTERECTOMY
POSTPARTUM

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

__________________________________________________________

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

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

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*

___________________________________________________________

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.

____________________________________________________

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

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 _________________________________________

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

Current Birth Control Method.*

SELECT OPTIONS

NONE
CONDOMS
NEXPLANON
MIRENA
ABSTINENCE
THE PILL
OTHER

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

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

SELECT OPTIONS

WHITISH
FEMININE ODOR
YELLOWISH
CLEAR
GREENISH
BLOOD TINGED
NONE OF THE ABOVE

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

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!