Pelvic Steam Screening Form - Non-Menstruator Preferred Name * First Name Last Name Your Email * 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. BLEEDING CONTRAINDICATIONS A bleeding contraindication means it is not safe to steam at this time. Please mark any of the following bleeding contraindications that apply: Are you currently experiencing fresh ongoing bleeding? (genitalia, rectum) * Yes No Not Sure Do you currently have fresh spotting? * Yes No Not Sure Have you had spontaneous bleeding within the past 3 months? * Yes No Not Sure Are you pregnant? * Yes No Not Sure If trying to conceive are you past ovulation? * Yes No Not Sure N/A If trying to conceive 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. Please mark any of the following soft contraindications that apply: Do you have an infection characterized with a burning itch? Yes No Not Sure Do you have tubal coagulation (burning of the fallopian tubes through laparascopic surgery through the belly button)? Yes No Do you have a birth control arm implant (i.e. Nexplanon)? Yes No Have you had uterine ablation procedure (where the uterine walls are burned so they scar over)? Yes No 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. If you have a burning itch the warmth from the steam could be uncomfortable since there is already so much heat in your body. In this case, you could try doing a sitz bath with cooling herbs. It is also recommended to seek treatment from an herbalist or acupuncturist to address the underlying imbalances causing the burning itch. Once the burning itch is resolved you are cleared to steam with a steam plan. We can discuss this further, but please go ahead and complete the entire screening form so I have as much information as possible. Thanks! SENSITIVITIES 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 we will adjust your steam session and herbs to perfectly apply to your needs. Let's see if you have any sensitivities. Please mark all sensitivities that apply: Is it your first time doing a steam session? Yes No Not Sure Are your menstrual cycles currently or historically ever 27 days or shorter? Yes No Not Sure Have you experienced any hot flashes over the past month? Yes No Not Sure Have you experienced any night sweats over the past month? Yes No Not Sure Do you have an IUD in currently? Yes No Are you currently or historically prone to yeast infections? Yes No Not Sure Are you currently or historically prone to BV (Bacterial Veginosis)? Yes No Not Sure Do you have herpes? Yes No Not Sure Do you have the Nuva Ring in? (If so, it should be removed prior to the steam session) Yes No Are you 13 or younger? * Yes No Do you have a history of spontaneous bleeding or two periods per month (4 months or later in the past)? Yes No Not Sure Please provide further information for any "Not Sure" responses: IMPORTANT Any "Yes" responses in the Sensitivity Category indicate a sensitivity in which case a steam plan provided by a steam therapist is highly recommended for your safety and best healing outcomes. NO PERIODS If you don't have periods what is the reason? (Please mark all that apply) * Hysterectomy Pregnancy Postpartum Postmenopause Depo-Provera Birth Control Shot Oral Birth Control IUD I'm Not Sure -- they are absent. Other That's it! Thank you for completing this pelvic steam screening form. After you click submit you can watch for a detailed email I will be sending you soon describing next steps in the process of scheduling a pelvic steam consultation. Thank you!
