Pelvic Steam Screening Form - Menstrual Cycles Preferred Name * First Name Last Name Your Email * HARD CONTRAINDICATIONS - There are times when it is not beneficial to steam. As a first step, let's check and make sure it's ok for you to have a pelvic steam session. UTERINE BLEEDING HARD CONTRAINDICATIONS A hard contraindication means it is not safe to steam at this time. Please mark any of the following hard contraindications that apply: Are you currently on your period or experiencing fresh ongoing bleeding? * Yes No Not Sure Do you currently have fresh spotting or had it in the past 24 hours? * Yes No Not Sure PREGNANCY HARD CONTRAINDICATIONS Are you pregnant? * Yes No Not Sure Is there a possibility you are pregnant? * Yes No Not Sure If trying to conceive are you past ovulation? * Yes No Not Sure N/A If receiving fertility assistance are you past IUI/IVF transfer? * Yes No Not Sure Please provide more information here for any responses that are "not sure". IMPORTANT Any “Yes” responses in the above section indicate that pelvic steaming is contraindicated. It is not safe to steam and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not happen at this time. If this is the case, I will explain next steps once the entire intake form is completed and submitted. Please go ahead and fill in the rest of the form so I can have as much information as possible to guide you. SOFT CONTRAINDICATIONS A soft contraindication means you can steam but need to be aware of certain side effects that apply to you. UTERINE BLEEDING SOFT CONTRAINDICATION Please mark any of the following soft contraindications that apply: Have you had spontaneous heavy bleeding within the past 3 months? Yes No Not Sure Have you had 2 periods per month (a period every 19 days or less) within the past 3 months? * Yes No Not Sure MEDICAL SOFT CONTRAINDICATIONS Do you have tubal coagulation (this is a type of "tube tying" where the fallopian tubes are fused together)? * Yes No Not Sure Do you have a birth control arm implant (i.e. Nexplanon)? Yes No Not Sure Have you had uterine ablation procedure (where the uterine walls are burned so they scar over)? * Yes No Not Sure Do you have an Essure insert? Yes No Not Sure Are you within 6 weeks post surgery? * Yes No Not Sure Have you hade a uterine fibroid embolization procedure? * Yes No Not Sure Please provide further information for "Not Sure" responses: IMPORTANT If you are using the above birth control methods it is possible that pelvic steaming could cause birth control failure. Steaming is not recommended unless you are okay with using a backup form of birth control or you are not concerned with your birth control failing. That's it! Thank you for completing this pelvic steam screening form. After you click submit you can watch for a detailed email describing next steps in the process of working with me on your customized steam plan. Thank you!
