Honey Pot Intake Form
2720 Sheraton Dr. Building D. Suite 250
Macon, GA 31204
478-216-3166
There are times when it is not beneficial for a women to steam. First, let's check and make sure that you don't have any contraindications. Please answer the following questions to the best of your ability.
Name *
Your answer
Email *
Your answer
Are you on your menstruation? *
Your answer
Do you currently have fresh spotting? *
Your answer
Do you ever have two periods per month? *
Your answer
Do you have spontaneous bleeding? *
Your answer
Do you have an infection characterized with a burning itch? *
Your answer
Are you pregnant? *
Your answer
If you trying to conceive are you past ovulation? *
Your answer
Do you have tubal coagulation burning of the fallopian tubes (through laparoscopic surgery) *
Your answer
Do you have a birth control arm implant (i.e. Nexplanon)? *
Your answer
Some women are very responsive to steam and it can cause a physiological response. If you are in this category then it is okay to steam, however your practitioner will adjust your steam session and herbs so that it perfectly suits you. *
Your answer
Is this your first time doing a yoni steam session? *
Your answer
Are your menstrual cycles currently or historically ever 27 days or shorter? *
Your answer
Have you experienced any night sweats over the past month? *
Your answer
Do you have an IUD in? *
Your answer
Are you currently or historically prone to yeast infections? *
Your answer
Are you currently or historically prone to bacterial vaginosis? *
Your answer
Do you have herpes? *
Your answer
Do you have the nuva ring in? (If so, it should be removed prior to steam session) *
Your answer
Are you age 13 or younger? *
Your answer
Do you have hot flashes, night sweats or an aversion to heat? *
Your answer
WAIVER: Most of the side-effects reported while steaming are positive. Users have reported better sleep, decreased swelling in legs and feet, decreased abdominal bloating, increased libido, fewer PMS symptoms, increased energy, lucid dreams, tingling feet, glowing skin, increased lubrication. However, some undesirable side effects might also occur. These include shortened menstrual cycles, onset of bleeding, headaches, the sensation to urinate or an infection outbreak. In 99% of all cases using a mild steam session and mild herbs will prevent the above from happening so it's very that you give honest answers in this intake form so that the practitioner knows the proper safety standards regarding setting up a yoni steam session tailored to fit your needs. PLEASE INITIAL BELOW AFTER READING: *
Your answer
Please sign your name below when you have completed and read the waiver. I understand that yoni steaming may have positive or negative side effects as a result of doing 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 names side effects (or others) may occur. *
Your answer
Date Completed: *
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