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Geyser
Geyser

Peristeam Facilitator Intake Form

Please note that this intake form does not apply if you are postpartum (0-12 months) or if you experienced a recent pregnancy loss (and the period has not yet returned). For steam plans egarding these situations please seek a consultation with a Peristeam Hydrotherapist.

Date
Month
Day
Year
Birthday
Month
Day
Year

Reproductive Organs

Which of the following is a reproductive organ you were born with?

Hard Contraindications

There are times when it is not beneficial for someone to steam. As a first step, let's check and make sure that you are safe for a steam session at this time.

Are you currently on your period or experiencing fresh ongoing bleeding?
Have you had any fresh spotting during the past 24 hours?
Have you had spontaneous heavy bleeding within the past 3 months?
Have you had 2 periods per month (i.e. a period every 19 days or less) within the past 3 months?

Pregnancy Contraindications

Are you pregnant?
Is there a possibility you are pregnant?
If you are receiving fertility assistance, are you past ovulation or IUI/ IVF transfer?

Soft Contraindications

Have you had tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?
Do you have a birth control arm implant or patch (i.e. Nexplanon)?
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?
Do you have an Essure insert?
Are you within 6 weeks post-surgery?
Have you had a uterine fibroid embolization procedure?

Heat Contraindications

Do you have a genital or rectal infection characterized with a burning sensation?

Steam Sensitivites

Some people are very responsive to steam and it can cause a physiological response, if you are in this category then it is ok to steam, however your practitioner will adjust your steam session & herbs so that it suits you, Let's see if you have any steam sensitivities.

Uterine Bleeding Sensitivity

Are your menstrual cycles currently or historically ever 27 days or shorter?
Do you have a history of spontaneous bleeding or 2 periods per month(3 months ago or later in the past)?

Medical Sensitivities

Do you have a Nuva Ring in?
Do you have an IUD?

Heat Sensitivities

Have you experienced any hot flashes in the past month?
Have you experienced any hot flashes in the past month?
Have you experienced any night sweats in the past month?
Are you currently or historically prone to yeast infections?
Are you currently or historically prone to bacterial vaginosis?
Are you currently or historically prone to urinary tract infections or bladder infections?
Do you have active or dormant herpes?

Age Sensitivity

Are you age 13 or younger?

First Timer

Is this your first time doing a steam session?
If you don't have periods what is the reason?

Herb Selection

It is best to select herbs suitable to your constitution. As your practitioner, I will use the information provided in this intake form to select a suitable herbal formula tailored to your specific needs.

Indicators for a Hemostatic Herb Formula

Do you ever have menstrual cycles that are 27 days or less?
In the past month did you have any fresh spotting on menstrual cycle day 27 or earlier?
Have you had any ongoing bleeding (bleeding that lasts 10 days or longer of fresh blood)in the past 3 months?
Do you have a history of spontaneous bleeding or 2 periods per month?
Are you 12 years of age or younger?

Indicators for a Cooling Herb Formula

Do you have Vaginal dryness?
Have you experienced hot flashes recently?
Have you experienced night sweats recently?
Do you have any type of dry genital infection (without discharge)?
Is the weather currently very hot?
Do you have an aversion to heat?
Do you radiate heat?

Indicators for a Cleansing Herb Formula

Are your menstrual cycles 28 days or longer?
Is menstrual cycle absent or missing because of known or unknown reason? Or are you a non-menstruator (born without uterus)?
Are you currently taking birth control pills?
Do you have any known or suspected plant or food allergies?

Cloaking

Mark all excess heat indicators that apply

Do you have hot flashes?
Do you have night sweats?
Do you radiate heat?
Are you prone to genital infections or viruses?
Is it currently hot weather?
Do youhave an aversion to heat?

Steam Questionnaire:

Steaming is very effective at overhauling the reproductive health system when done weekly for three to six months or until all issues resolve. Menstruators will want to do a new intake form with their Peristeam Faciliator after every menstrual cycle to see if the herbs or set up need adjustment, which commonly is the case.

Which of the following would you be interested in?

Weekly Steaming, as well as steaming before & after the period can be very effective for optimizing health. Dedicating to this steam schedule for 3-6 months can be very effective. It is also useful for menstruators to steam three times before & three times after the period. For advanced steam concerns or issues it may be useful to do an additional, more in-depth consultation with a Peristeam Hydrotherapist to get a specific steam plan for that issue. So that I can create the best steam plan for you, please let me know which of the following you are interested in.

Mark all that apply:
Where do you plan to Steam?
Do you need recommendations/assistance for any of the following?
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