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Client Intake Form

Equine Massage Intake link.

“https://form.jotform.com/241154611308043”

Pelvic Steaming Intake.

    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

    Are you currently on your period?
    Do you currently have fresh spotting?
    Have you had spontaneous bleeding within the past 3 months?
    Have you had two periods per month in the past 3 months?
    Are you pregnant?
    If trying to conceive are you past ovulation?


    IMPORTANT

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

    Do you have an infection characterized with a burning itch?
    Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?
    Do you have a birth control arm implant (i.e. nexplanon)?
    Do you have an Essure insert?
    Are you breastfeeding?
    Have you ever had surgery? If yes, please indicate what kind(s) and date(s) in Notes below.
    Have you had any other procedures done on your genital area in the past 2 months? If yes please describe what kind(s) and date(s) in Notes below.

    IMPORTANT

    If you are using certain birth control methods vaginal steaming could cause a birth control failure. 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 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 or wait until the burning sensation is gone before doing a vaginal steam session. You could also try doing a sitz bath with cooling herbs. If you have had a uterine ablation procedure (to scar over the uterine walls) it is possible that vaginal steaming will clear the scar tissue reversing the surgery.

    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 your practitioner will adjust your steam session and herbs so that it perfectly suits you. Please Mark All That Apply

    Is this your first time doing a steam session?
    Are your menstrual cycles currently or historically ever shorter than 28 days?
    Have you experienced any hot flashes over the past month?
    Have you experienced any night sweats 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 bleeding or two periods per month (4 months or later in the past)?

    IMPORTANT

    The above "yes" replies indicate sensitivity in which case a mild setup without a burner should be used. Under no circumstances should clients who have sensitivity use an advanced setup with a burner.

    Herb Selection

    It is best to select herbs suitable to your constitution. Your practitioner will use the info from this intake form to select a suitable vaginal steam formula for you.

    Indicators for Cleansing Herbs

    Are your menstrual cycles 28 days or longer?
    Is your menstrual cycle absent or missing for an unknown reason or because of birth control?
    Are you currently taking birth control pills or using other hormonal birth control?


    Indicators for Gentle Herbs

    Do you ever have menstrual cycles shorter than 28 days?
    Do you have fresh spotting between periods?
    Are you currently under age 13?


    Indicators for Disinfecting Herbs

    Do you have green vaginal discharge?
    Do you have yellow vaginal discharge?
    Do you have white vaginal discharge?
    Do you have thick vaginal discharge?
    Do you have malodorous vaginal discharge?


    Indicators for Cooling Herbs

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


    Do You Have Any Food or Plant Allergies?

    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. 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.

    Mark All Excess Heat Indicators that Apply

    Do you have hot flashes?
    Do you have nightsweats?
    Do you radiate heat?
    Are you prone to infections or viruses?
    Is the weather hot?
    Do you have an aversion to heat?

    Yes answers may indicate excess heat in which case cloaking is not necessary. Instead we will use a towel, light robe, steam gown, summer dress or light wrap-around fabric.

    No Periods

    If you don't have periods what is the reason?
    HysterectomyPregnancyPostpartumPostmenopauseHaven't Had First Period YetDepo-Provera Birth Control ShotOral Birth ControlIUDI'm not sure -- they are absentOther

    WHAT TO EXPECT
    Steaming is a cleanse. Some of the possible signs the vaginal steaming is working include -- 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, 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 changes and inform your practitioner.

    BEST PRACTICES
    1) Go to the bathroom directly prior to vaginal steaming.
    2) Learn proper period care. Avoid tampon use and instead use 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, 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 the period and to eat the right foods.
    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.

    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 plan or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur please let your practitioner know so they can adjust the steam session as necessary or make a referral.

    In most 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 the practitioner can set up a steam session that will fit your needs.

    INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

    Vaginal steaming may have many benefits, but, like any treatment, it also has some risks. It’s important that you read the below and understand these risks before having any treatments. We require that sign this agreement to indicate that you understand an assume these risks before we provide you with any products or services.

    Practitioner Name: Jaime Smith
    Practitioner Company: Olden Wayz New Dayz

    THIS AGREEMENT is made between Practitioner Name and Company (as typed in the field above) (“Company”) and Client (as typed in the field above) ("I") (collectively the “Parties”).
    I have purchased or am receiving complimentary steaming services, products or a consultation from Company (the "Products and/or Services").

    I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in, or cause me to have an adverse reaction to, the Services, including but not limited to preterm pregnancy. I affirm that I have reviewed the “Best Practices” and other information provided to me by Company or its agents. I further affirm, that all information provided to Company by me is accurate and complete and I understand that failing to provide information may result in a greater risk of injury. I acknowledge that my purchase and participation in or use of the Products and/or Services is voluntary and I do so entirely at my own risk. I acknowledge that I have approval from my doctor or medical professional to use or receive the Products and/or Services or I yield that requirement and take responsibility for my own medical decision-making.
    I understand that results may vary from person to person. I understand that I may react adversely to the Products and/or Services and they may result in injury to me. Side effects include, but are not limited to, rash, bumps, burns, irritation, miscarriage, interference with effectiveness of birth control, infection, headaches, itchiness, diarrhea, increased vaginal discharge, cramping or the onset of fresh spotting or inter-period bleeding. If I elect to continue Products and/or Services after such results, I will alert Company to issues so that the Products and/or Services may be suspended, adjusted, or a referral can be made. I expressly agree that all risk of injury that I undertake as a part of the Products and/or Services is undertaken at my sole risk.
    I further expressly agree that I will not use any equipment related to the Products and/or Services improperly. If equipment is located on the Company premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release Company, its agents and employees from any claim, demands, injuries, damages, actions, or causes of action, that could occur from my inappropriate use of such equipment.
    I affirm that I have confirmed on [your website] that Company’s practitioner has a vaginal steam specialist certification.
    I also understand and agree that all information provided before, during, or after the Products and/or Services is for informational purposes only and is not medical advice or a replacement for medical advice from a medical professional. The Products and/or Services and information provided therein are not medical treatment, and do not replace the relationship between physician/therapist and a client in a one-on-one treatment session with an individualized treatment plan based on their professional evaluation. I will not rely on the Products and/or Services as an alternative to advice from my medical professional or healthcare provider and I will never delay seeking medical advice, disregard medical advice, or discontinue medical treatment as a result of any information provided before, during, or after the Products and/or Services. The Products and/or Services and any information therein are provided "as is" without any representations or warranties, express or implied.

    Company, its agents and employees, shall not be liable to me for any claims, demands, injuries, damages, actions or causes of action to my person or property arising out of or connected with the Products and/or Services and the premises where the Products and/or Services are located. I expressly release Company, its agents and employees from all such claims, demands, injuries, damages, actions, or causes of action, and from all acts of active or passive negligence on the part of Company, to the extent such a release of negligence is permissible by law.
    I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during the Products and/or Services. In the event of sickness, accident, or injury, I authorize Company and its representatives to obtain, on my behalf, emergency medical treatment at my expense.
    This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. This Agreement shall be construed and enforced according to the laws of the State of Washington and any dispute under this Agreement must be brought in the courts of Benton County, Washington venue and no other.

    I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I UNDERSTAND AND AGREE THAT I AM GIVING UP LEGAL RIGHTS BY SIGNING THIS AGREEMENT AND THAT I AM DOING SO VOLUNTARILY, FREELY, UNDER NO THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE, OR GUARANTEE BEING COMMUNICATED TO ME. THE SIGNATURE BELOW IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW.
    My printed name and date below represent my signature.

    By clicking SEND you acknowledge that you have read the waiver and the information provided is true to the best of your knowledge.

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