Intake Form ~ The Nourished Woman

Name:*

First

Last

Address:

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

E-mail:*

Phone:*

Area Code

Phone Number

Date of Birth*

Are you currently pregnant?*

yes

Is there a chance that you might be pregnant?*

yes

How did you hear about Nourished Woman/Happy Yoni Vaginal Steaming?*

Have you ever had a vaginal steam before?*

yes

regularly

at a spa

If you are not steaming with a Nourished Woman Steam Box, please tell us how you plan to steam. Please note that our results and level of effectiveness is based on using an enclosed steam sauna, such as a Nourished Woman Steam box, made with safe wood and using an herbal water vessel which adequately retains heat. We strongly encourage attention to the details for desired outcome. If you have purchased a Nourished Woman Steam box simply say so.*

What age were you at your first menstrual cycle?*

Are there any herbs that you are allergic to? Please list them here or simply type "none" if you have no allergies.*

Do you suffer from menstrual cramps? If so please check all that apply.*

If applicable, when was your last most recent menstrual bleed. If not applicable please type n/a*

Do you feel your cycle can prevent you from living your normal day?*

some months

every month

no longer bleed

Please indicate the length of your typical monthly cycle. Your monthly cycle is how long it is from the first day of a bleed to the day before your next bleed.*

If you selected varying cycle length or don't know my cycle length or bleed length please expand/describe. Include approximate shortest and longest cycle length.

Do you have skipped bleeds or suffer from Amenorrhea?*

yes

How many children have you birthed?*

Please check any of the following conditions that you experience on a regular basis, although perhaps not currently.*

How would you score the comfort of your average menstrual cycle? One star being very uncomfortable and 5 stars being very comfortable

How would you score your general level of health? One star being very unhealthy and five stars being very healthy.

How active are you on a weekly basis, one star being inactive and 5 stars being very active.

Do you consider yourelf to be... (check all that apply)*

If you have noticed tempertaure patterns within yourself, please expand.

How comfortable are you talking about your menstruation and or Ladyscape, one star being very uncomfortable and 5 stars being bring it on!

Do you wish to expand on anything or is there anything else important that you feel we should know? If so please use the space provided below.

Do you have any questions or concerns before we begin your personal vaginal steam plan?

What do you hope to accomplish through vaginal steaming?

When to avoid Vaginal Steaming; If you are pregnant or there is a possibility of pregnancy. During or after ovulation if you are trying to conceive. During Menstruation. If you have had heavy spontaneous bleeding mid-cycle within the last three months it is not recommend to do a vaginal steam. It is not recommended to steam after waxing or laser hair removal. We recommend waiting 4 days after waxing and 2 weeks after laser hair removal. Please note that piercings will need to be removed to avoid burns. *

I understand

IUD Precautions; Steaming is considered safe with a copper IUD. We do not encourage use with a plastic IUD or plastic intrauterine contraceptive device device including coil, loop, triangle or T shape made of anything other than copper.*

I understand

Steaming should not be done when the body is fighting and illness such as the flu or any other fevered condition. When the body is fighting an active infection resting is a priority over steaming. It is important that you listen to your body first and foremost over all guidelines. You should stop your steam if you feel any of the following; generally unwell, light headed, dizzy, nauseous, intense headache, short of breath or if your body tells you so, trust your instincts.*

I understand

Burn risk; Just like drinking a hot beverage like tea or coffee there is a chance to burn yourself if you do not first test the temperature by placing a sensitive part of your body, like the inside of your elbow, over your box. *

I understand and agree to test the temperature to make sure it is suitable for me before I steam

I agree to never carry my Nourished Woman Steam box, or other box, with a vessel/pot of hot water in it.*

I agree

I certify that I am above the age of 18 years old.*

I am 18 years old or older

I am filling this out for someone who is under the age of 18

LIABILITY AGREEMENT; I certify that the above information is true and complete, to the best of my knowledge. I fully understand that I am solely responsible for my health, safety and well-being while vaginal steaming. I agree to consult my physician if I am in doubt of my ability to use the Vaginal Sauna for health reasons. I understand that the use of drugs, medication or alcohol prior to or during the vaginal steam session may lead to dizziness or unconsciousness. I will discontinue the use of the vaginal steam immediately if I feel light-headed, dizzy, heat exhausted, feel unwell or my body or intuition tells me to do so. I understand I should drink plenty of water before and after a vaginal steam session. I understand that there are risks associated with any health treatment including vaginal steaming. While every precaution shall be taken to ensure the good welfare during a steam session or in the preparation of herbs or a personal steam plan, The Nourished Woman Team, staff members, employees, volunteers, or facilities are hereby released from any liability in the event of any accident or misfortune that may occur from the result of vaginal steaming.*

I have read and agree to the Liability Agreement