Yoni Steaming Intake Form

Yoni Steaming Intake Form

Provided by Yoni Eggs South Africa
Client Name*

First NameLast Name
Client Email*
Did someone refer you to this consultation? (eg yoni steaming herbs supplier, friend, etc) Please give their name if so or type NONE if not. *
Country of Residence (for recommended herbs and supplier local to you if you are not based in South Africa)*

Age

	Please select one
13 years or under
14-35 years
36-45 years
46-55 years
55 years or older

Please read the questions carefully and answer each one honestly: check YES or NO or NOT SURE or SOMETIMES.
Contraindications

There are times when it is not beneficial for a woman to steam. First, let's check and make sure that you don't have any contraindications.

Please mark any of the following that apply:-*

	Yes	No	Not Sure
Are you currently on your period?
Do you currently have fresh spotting/bleeding of any kind?
Have you had spontaneous heavy bleeding anytime within the past 3 months?
Have you had two periods per month anytime in the past 3 months?
Are you pregnant?
If trying to conceive are you past ovulation (usually days 14-16)?

IMPORTANT

The above "Yes" replies indicate that yoni steaming is currently contraindicated. It is not safe and could result in negative side effects such as the onset of heavy bleeding or a miscarriage. Steaming should not be performed at this time under any circumstances.

Please mark any of the following that apply:-*

	Yes	No	Not Sure
Do you have an infection characterised by a burning itch?
Do you have tubal ligation ("tying" of the Fallopian tubes by burning them through laproscopic surgery via the belly button) as a form of birth control?
Do you have a birth control arm implant (eg Nexplanon)?
Do you have an Essure implant in your Fallopian tubes as a method of birth control?
Have you had a uterine ablation (burning of uterus lining) in order to reduce heavy menstrual flow?

IMPORTANT

If you have a burning itch, the warmth from the steam could be uncomfortable since there is already so much heat in that area. In this case it is best to seek treatment from an acupuncturist to get the burning sensation to go away prior to doing a yoni steam session - or to take cooling, herbal "sitz" baths (using yoni steaming herbs) instead until the burning has subsided.

If you are using the above birth control methods, yoni steaming could cause a birth control failure, due to removal of scar tissue or mucus build-up. 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, yoni steaming could remove the scar tissue from the uterus lining, effectively reversing this procedure.

YONI STEAMING UNDER ANY OF THESE CIRCUMSTANCES IS POSSIBLE - BUT TOTALLY AT YOUR OWN RISK.
ANY FURTHER NOTES YOU WOULD LIKE TO ADD ON THE ABOVE?
Sensitivities

Some women 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 I will adjust your steam session and herbs to suit your constitution.

Please mark all that apply:-*

	Yes	No	Not Sure
Is this your first time doing a steam session?
Are your menstrual cycles currently or historically 27 days or shorter?
Have you experienced any hot flushes over the past month?
Have you experienced any nightsweats over the past month?
Do you have an IUD in?
Are you currently or historically prone to yeast infections?
Are you currently or historically prone to bacterial vaginosis?
Do you have herpes?
Do you have the Nuva Ring in? (If so, it should be removed prior to steam session)
Are you age 13 or younger?
Do you have a history of spontaneous heavy bleeding or two periods per month (4 months or later in the past?

ANY FURTHER NOTES YOU WOULD LIKE TO ADD ON THE ABOVE?
Herb Selection

It is highly advisable to select herbs suitable to your constitution. I will use the info from this intake form to select a suitable yoni steam formula for you.

Indicators for Cleansing Herbs*

	Yes	No
Are your menstrual cycles 28 days or longer?
Is your period absent or missing for an unknown reason or because of birth control?
Are you currently taking any kind of hormonal birth control - eg via pills, injection, the Mirena, etc?

Indicators for Soothing Herbs*

	Yes	No
Do you ever have menstrual cycles 27 days or less?
Do you have fresh spotting between periods?
Are you currently under age 13?

Indicators for Purifying Herbs*

	Yes	No	Sometimes
Do you have green vaginal discharge?
Do you have yellow vaginal discharge?
Do you have white (not clear) vaginal discharge?
Do you have thick vaginal discharge?
Do you have malodorous (bad smelling) vaginal discharge?

ANY FURTHER NOTES YOU WOULD LIKE TO ADD ON THE ABOVE?

Indicators for Cooling (Moisturising) Herbs*

	Yes	No
Do you have vaginal dryness?
Have you experienced hot flushes recently?
Have you experienced nightsweats recently?
Do you have any type of dry vaginal infection (without vaginal discharge)?
Is the weather where you are currently very hot?
Do you have an aversion to heat?
Do you radiate heat (always the warmest one in bed!)?

DO YOU HAVE ANY FOOD OR PLANT ALLERGIES? PLEASE LIST IF SO:-*
Specific Issues

Some of these may have been covered before - but please complete so I have a full overview of any specific issues you are dealing with.

Do you experience/are you experiencing any of the following:-*

	Yes	No
PMS?
Painful periods?
Irregular or absent periods?
Difficulty conceiving?
Post-partum (or soon to be)?
Fibroids?
PCOS/Ovarian cysts?
Painful or numb scar tissue (vaginal/cesarean)?
Haemorrhoids?
Herpes?
Chronic vaginal/yeast infections?
Pelvic organ prolapse?
Vaginal dryness?
Pain during sex?

Menopause*

Yes No

Are you post-menopause?
ANY FURTHER NOTES YOU WOULD LIKE TO ADD ON THE ABOVE - OR YOUR REASONS FOR WISHING TO YONI STEAM?
Cloaking

When steaming it is often commonplace to wear a cloak or steam gown. Cloaking helps to increase the benefit of the treatment by enhancing the detoxification of the session. A couple of notes of caution:- Firstly, it is not advised to use plastic as a cloak as it is very likely to release toxins (in particular, endocrine/hormone disruptors) when heated. Secondly, cloaking is not a good idea if you already have excess heat in your body. Let's check to see if you have any signs of excess heat:-

	Yes	No
Are you post-menopause?

Mark all excess heat indicators that apply:-*

	Yes	No
Do you have hot flushes?
Do you have nightsweats?
Do you radiate heat (always the warmest one in bed!)?
Are you prone to infections or viruses of any kind?
Is the weather very hot where you are now?
Do you have an aversion to heat?

ANY FURTHER NOTES YOU WOULD LIKE TO ADD ON THE ABOVE?
No Periods

If you don't have periods, what is the reason:-

	Tick at least one
Hysterectomy
Pregnancy
Post-partum
Post-menopause
Haven't had first period yet
Depo-Provera birth control shot
Oral birth control
IUD
I'm not sure
Other (please give details in box below)

ANY FURTHER NOTES YOU'D LIKE TO ADD ON THE ABOVE:-
DO YOU HAVE ANY QUESTIONS OR HESITATIONS PRIOR TO YOUR YONI STEAMING SESSION?
Waiver

(PLEASE READ)
Most of the side-effects reported while steaming are positive. Users have reported better sleep and lucid dreams; relaxation; decreased swelling in legs and feet; decreased abdominal bloating; slimmer waistline; increased libido and sexual sensation; increased Amrita (female ejaculate/vaginal nectar) and fertility; decrease in breast soreness; fewer headaches; fewer PMS symptoms and improved emotional balance; increased circulation and energy; tingling feet; glowing skin; reduction in incidence of hormonal acne; increased lubrication; scar tissue softening; more toned vaginal canal; and harmonisation with the moon cycle.

WHAT TO EXPECT
Steaming is a cleanse. Some of the possible signs that yoni steaming is working is if you experience... The urge to urinate while steaming; brown discharge after steaming; increased clots or cramps during the period; increased dry cramps; increased irregular vaginal discharge (white, yellow, green, thick, clumpy); emotional release; periods that come earlier or later than expected. All of these signs are a normal part of the cleansing process and these signs will go away once the cleanse is complete. Please note these positive changes and let me know about them.

BEST PRACTICES
1) Go to the bathroom directly prior to yoni steaming.

2) Learn proper period care. Avoid tampon use (the blood is supposed to flow out of the body) and instead use organic cotton pads or period panties. The period is a uterine cleanse and if you support it the clots can easily clear out. Plugging up with tampons - or even mooncups - on the other hand, prevents the old residue from clearing out and that is often the cause of cramping. It's also important to rest during your period and to eat the right foods. More information on proper nutrition/holistic sexual self-care will be found via my upcoming Yoni Vitality membership site (visit www.yonieggs.co.za and sign up to my mailing list for details of when this opens for enrollment).

3) Increased vaginal discharge can be addressed by using cotton underwear liners and a peri-bottle throughout the day to clean mucus off the skin, if necessary.

CAUTION SIGNS
If steaming causes a rash, bumps, headaches, itchiness, diarrhea or the onset of fresh spotting or inter-period bleeding, this could be a sign that your steam protocol or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur please let me know so that I can adjust the steam session as necessary or make a referral.

****

In 99% of all cases using a mild steam session and mild herbs will prevent any of the above signs from happening so it's very important that you give honest answers in this intake form so that I can set up a steam session that will fit your needs.

****

"I understand that yoni steaming may have positive or negative side effects as a result of doing a yoni steam session. I accept full legal responsibility for my choice to do a yoni steam session and waive the responsibility of the practitioner (and the facility where the steam session takes place, if not at my place of residence) fully and completely in the case that any of the named side effects (or others) may occur.

My printed name and date below represent my signature and agreement to the above."
Full Name (Signature)*

First NameLast Name
Date of Signature*
For Practitioner Use Only

Which setup would be best?

	Yes	No
Steaming is Contraindicated
Mild Session
Advanced Session
Cleansing Herbs
Soothing Herbs
Purifying Herbs
Cooling Herbs
Cloak

What Steam Schedule Do You Recommend?

(Weekly; 3x Before/After the period; or Specialised)
Should be Empty:

Yoni Steaming Intake Form

Contraindications

Sensitivities

Herb Selection

Specific Issues

Cloaking

No Periods

Waiver