Contact Information
Today's Date
Today's Date
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Their name, your relationship to them and their phone number
Reason for Visit
What do you attribute this to?
All About Your Cycle
Date of Last Period
Date of Last Period
Average day of cycle (for example 28 days). If irregular, note how they are irregular here.
If so, what size and color?
If so, how do you experience it?
Reproductive History
Y/N If so, what kind?
Y/N Feel free to discuss any changes you may notice.
Reproductive Symptoms
In order to best formulate your herbal steam blend, please check any that apply.
I am aware of the contraindications of steaming, listed below. By signing this form, I agree that they do not currently apply to me. You should NOT steam if any of the following apply: ❂ You’re currently menstruating ❂ You’re pregnant ❂ You’re currently miscarrying ❂ You’re prone to spontaneous, heavy bleeding ❂ You’re trying to conceive and have already ovulated Use caution if: ❂ You have an IUD, as this carries a small but possible risk of expelling the IUD
Please take a moment to carefully read the following information and sign by typing your initials below. If you have a specific medical condition or specific symptoms, herbal pelvic/vaginal steam bath may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner so that the temperature may be adjusted to my level of comfort. I further understand that pelvic/vaginal steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the pelvic/vaginal steam bath is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because pelvic/vaginal steam baths should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so. I am aware and I understand there is a possibility that my IUD can come out due to a Vaginal Steam Bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk. I understand that I am having this pelvic/vaginal steam bath at my own risk and hereby release Jeevan Singh from any liability.