Vaginal steaming form

CLIENT'S NAME

CLIENT'S LAST NAME

CLIENT'S EMAIL

CLIENT'S CONTACT NUMBER

CONTRAINDICATIONS

THERE ARE TIMES WHEN ITS NOT BENEFICIAL FOR A WOMAN TO STEAM, FIRST LETS MAKE SURE THAT YOU DONT HAVE ANY CONTRAINDICATIONS.

ARE YOU CURRENTLY ON YOUR PERIODS?

Yes

Not sure

DO YOU CURRENTLY HAVE FRESH SPOTTING?

Yes

Not sure

HAVE YOU HAD TWO PERIODS PER MONTH IN THE PAST 3 MONTHS?

Yes

Not sure

ARE YOU PREGNANT?

Yes

Not sure

IF TRYING TO CONCEIVE, HAVE YOU PASSED OVULATION?

Yes

Not sure

IMPORTANT

THE ABOVE 'YES" REPLIES INDICATE THAT VAGINAL STEAMING IS CONTRAINDICATED. IT IS NOT SAFE AND COULD RESULT IN A NEGATIVE SIDE EFFECT SUCH AS THE ONSET OF BLEEDING OR A MISCARRAIGE, STEAMING SHOULD NOT BE PERFORMED AT THIS TIME.

DO YOU HAVE AN INFECTION CHARACTERISED WITH A BURNING ITCH?

Yes

Not sure

DO YOU HAVE TUBAL COAGULATION (BURNING OR FALLOPIAN TUBES)?

Yes

Not sure

DO YOU HAVE AN IMPLANON?

Yes

Not sure

IMPORTANT

IF YOU ARE USING THE ABOVE BIRTH CONTROL METHODS, VAGINAL STEAMING COULD CAUSE A BIRTH CONTROL FAILURE. IT IS NOT RECOMMENDED UNLESS YOU HAVE A BACKUP FORM OF BIRTH CONTROL OR YOU ARE NOT CONCERNED ABOUT POSSIBLE PREGNANCY.

IF YOU HAVE A BURNING ITCH, THE STEAM COULD BE UNCOMFORTABLE SINCE THERE IS ALREADY SO MUCH HEAT IN THAT AREA

SENSITIVITY

SOME WOMEN ARE VERY RESPONSIVE TO STEAM AND IT CAN CAUSE A PHYSIOLOGICAL RESPONSE, IF YOU ARE IN THIS CATAGORY THEN ITS OKAY TO STEAM, HOWEVER YOUR PRACTITIONER WILL ADJUST YOUR STEAM SESSION AND HERBS SO THAT IT IS PERFECTLY SUITED FOR YOU.

IS IT YOUR 1ST TIME STEAMING?

Yes

Not sure

IS YOUR MESTRUAL CYCLE EVER 27 DAYS OR SHORTER?

Yes

Not sure

HAVE YOU EXPERIENCED ANY HOT FLASHES OVER THE PAST MONTH?

Yes

Not sure

DO YOU HAVE AN IUD INSERTED?

Yes

Not sure

ARE YOU CURRENTLY OR HISTORICALLY PRONE TO INFECTIONS?

Yes

Not sure

DO YOU HAVE HERPES?

Yes

Not sure

ARE YOU AGE 13 OR YOUNGER?

Yes

Not sure

DO YOU HAVE A HISTORY OF SPONTANEOUS BLEEDING OR TWO PERIODS PER MONTH IN THE PAST 4 MONTHS (LESS THAN 16 DAYS APART)?

Yes

Not sure

NOTES

IMPORTANT

THE ABOVE "YES" REPLIES INDICATE SENSITIVITY IN WHICH CASE A MILD STEAM SETUP WITHOUT A BURNER SHOULD BE USED, UNDER NO CIRCUMSTANCES SHOULD CLIENTS WHO HAVE SENSITIVITY USE AN ADVANCE SETUP WITH A BURNER.

HERB SELECTION

IT IS BEST TO SELECT HERBS SUITABLE TO YOUR CONSTITUTION, YOUR PRACTITIONER WILL USE INFO FROM THIS FORM TO DETERMINE WHICH VAGINAL STEAMING FORMULAR WORKS BEST FOR YOU.

INDICATION FOR HAPPY CYCLE HERBS

IS YOUR MENSTRUAL CYCLE 27 DAYS OR SHORTER?

Yes

Not sure

DO YOU HAVE FRESH SPOTTING INBETWEEN PERIODS?

Yes

Not sure

ARE YOU CURRENTLY UNDER THE AGE OF 13?

Yes

Not sure

IF ANY "YES" REPLIES, THATS A SIGN FOR HAPPY CYCLE HERBS, THIS FORMULAR WILL ALWAYS BE THE BEST CHOICE.

INDICATION FOR CLEANSING HERBS

IS YOUR MENSTRUAL CYCLE 28 DAYS AND LONGER?

Yes

Not sure

IS YOUR CYCLE ABSENT OR MISSING FOR AN UNKNOWN REASON OR DUE TO BIRTH CONTROL?

Yes

Not sure

ARE YOU CURRENTLY ON BIRTH CONTROL?

Yes

Not sure

INDICATION FOR BALANCE HERBS

DO YOU HAVE GREEN VAGINAL DISCHARGE?

Yes

Not sure

DO YOU HAVE YELLOW VAGINAL DISCHARGE)?

Yes

Not sure

DO YOU HAVE WHITE VAGINAL DISCHARGE?

Yes

Not sure

DO YOU HAVE THICK VAGINAL DISCHARGE?

Yes

Not sure

DO YOU HAVE MALODOUROUS VAGINAL DISCHARGE?

Yes

Not sure

INDICATION FOR SOOTHING HERBS

DO YOU HAVE VAGINAL DRYNESS?

Yes

Not sure

DO YOU HAVE ANY TYPE OF DRY INFECTION?

Yes

Not sure

HAVE YOU EXPERIENCED HOT FLASHES RECENTLY?

Yes

Not sure

HAVE YOU EXPERIENCED NIGHTSWEATS RECENTLY?

Yes

Not sure

DO YOU HAVE AN AVERSION TO HEAT?

Yes

Not sure

DO YOU RADIATE HEAT?

Yes

Not sure

IS THE WEATHER CURRENTLY HOT?

Yes

Not sure

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 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 AND INCREASED LUBRICATION
AND VAGINAL NECTAR, SCAR SOFTENING, TIGHTER VAGINAL CANAL AND HARMONIZATION WITH THE MOON CYCLE.

WHAT TO EXPECT
STEAMING IS A CLEANSE. SOME OF THE POSSIBLE SIGNS THE VAGINAL 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, 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 LET YOUR PRACTITIONER KNOW OF THESE POSITIVE CHANGES.

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.

CAUTION SIGNS
IF STEAMING CAUSES A RASH, BUMPS, HEADACHES ITCHINESS, DIARRHEA OR THE ONSET OF FRESH SPOTTING OR INTERPERIOD 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 YOUR PRACTITIONER KNOW SO THEY 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 THE PRACTITIONER CAN SET UP A STEAM SESSION THAT WILL FIT YOUR NEEDS.

NOTE: IT IS BEST PRACTICE TO CHECK THAT YOUR VAGINAL STEAM FACILITATOR HAS A VAGINAL STEAM FACILITATOR CERTIFICATE IN GOOD STANDING. THIS CERTIFICATION ENSURES THAT YOUR PRACTITIONER KNOWS THE PROPER SAFETY STANDARDS REGARDING SETTING UP A VAGINAL STEAM SESSION TAILORED TO FIT YOUR NEEDS.

PLEASE CONTACT INFO@KWETSIMA.CO.ZA OR WHATSAPP 0815473026 TO VERIFY IF THE PERSON SELLING YOU STEAM PRODUCTS OR FACILITATING A STEAM SESSION IS QUALIFIED TO DO SO.

I UNDERSTAND THAT VAGINAL STEAMING MAY HAVE POSITIVE OR NEGATIVE SIDE EFFECTS AS A RESULT OF DOING A VAGINAL STEAM SESSION. I ACCEPT LEGAL RESPONSIBILITY FOR MY CHOICE TO DO A VAGINAL STEAM SESSION AND WAIVE THE RESPONSIBILITY OF THE PRACTITIONER AND THE FACILITY WHERE THE STEAM SESSION TAKES PLACE IN THE CASE THAT ANY OF THE NAMED SIDE EFFECTS (OR OTHERS) MAY OCCUR.

MY PRINTED NAME AND DATE BELOW REPRESENT MY SIGNATURE.

First Name

Last Name

Date / Time

PRACTITIONER USE ONLY

WHICH SET UP WOULD BE BEST?

STEAMING IS CONTRAINDICATED

Yes

CLEANSING HERBS

Yes

SOOTHING HERBS

Yes

MILD STEAM SETUP

Yes

HAPPY CYCLE HERBS

Yes

CLOAK

Yes

ADVANCED STEAM SETUP

Yes

BALANCE HERBS

Yes

NO CLOAK

Yes

WHICH SET UP WOULD BE BEST?

WEEKLY SCHEDULE

3X BEFORE/AFTER PERIOD

CONTRAINDICATIONS

IMPORTANT

IMPORTANT

SENSITIVITY

IMPORTANT

HERB SELECTION

WAIVER

PRACTITIONER USE ONLY

ADDRESS

PHONE

Operational Hours

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