V Steam

MoL.
RESOURCE GUIDES
- BLM
- FOOD [COVID-19]

MoL.
RESOURCE GUIDES
- BLM
- FOOD [COVID-19]

MoL.

V STEAM

UTERAN HEALTH INTAKE FORM

* Indicates required field

Name *

First

Last

Gender Identity *

ie. pronouns, preferred names

DOB *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

For shipping herbs

Moon Cycle

What was the first date of your last period? *

Typically, how long is your cycle? *

27 days or less 28-30 days 31-40 days Over 40 days It Changes / I Dont Know Missing Not sure

Are you historically prone to: *

27 day or shorter cycles yeast infection bacterial vaginosis bladder / urinary tract infection nightsweats hot flashes spontaneous bleeding or 2 menstrual cycles per month

Do you currently have fresh spotting between cycles? *

Yes No Maybe / Not Sure

Do you currently have vaginal discharge? *

No white green yellow thick malodorous I dont know

Are you currently experiencing vaginal dryness? *

Yes No Maybe

Do you currently have a dry vaginal infection, characterized by a rash or burning/itching sensations? *

Yes No Maybe

Do you experience cramps, PCOS or PMS before you bleeding? *

Cramps PCOS PMS All of the above A little / Sometimes No

Does your body temperature run hot (ie. radiate heat) or cold (ie. low circulation)? *

High/Hot temp Moderate/Neutral temp Low/Cold temp

Is the weather currently very hot? Do you have an aversion to heat?Choose Any *

Yes - hot weather Yes - aversion to heat No Not Sure / Maybe

Contraindications

Are you currently on your period *

Yes No Maybe

Have you had spontaneous heavy bleeding or two periods per month within the past 3 months *

Yes No Maybe

Are you currently on birth control pills? *

Yes No Kind of

Do you have any of the following: *

Birth Control arm implant Tubal coagulation Uterine ablation Essure Insert None

Is your cycle absent or missing because of an unknown reason or because of birth control? *

Yes No Maybe

If you dont have a period, what is the reason? *

Hysterectomy Pregnancy Postpartum Postmenopause Havent had first period yet Depo-Provera Birth Control Shot Oral Birth Control IUD Im not Sure -- they are absent Other

Are you pregnant? *

Yes No Maybe

Estimated Due Date: *

If trying to conceive, are you past ovulation or IUI/IVF transfer? *

Yes No Maybe Not trying to conceive Would like to work on fertility

Are you currently under age 13? *

No Yes

Please provide further information for responses with Yes or Maybe *

Health Screening

Sex *

Male Female Intersex Trans - Male to Female Trans - Female to Male

Blood Type *

A +/- B +/- AB O I dont Know

Do you have a blood deficiency or sensitivity (ie. anemia, high blood pressure, etc)? Please describe: *

Any dietary restrictions? Please Check all that apply. *

Vegan Vegetarian Pescatarian Gluten Free Sugar Free Paleo / Keto Other No dietary restrictions

Food or Plant allergies? *

Supplements and/or Medications? *

Favorite Food, Spice, Flower and/or Scent: *

What diseases and/or notable health traits run in your family? *

Have you had any major surgeries, medical procedures, ailments or injuries? *

How many times have you given birth? Vaginally or by C-section? *

Are you sexually active? *

Yes No Sometimes / Maybe

Do you experience pain during sex? *

Yes No Sometimes

Do you have any STDs? *

Yes No Maybe

Have you experienced sexual or womb trauma in your life? *

Yes No Maybe

Will this be your first steam session? *

Yes No Maybe

Anything else you want to share? What are you hoping to gain, relieve and/or heal with the ancient practice of vaginal steam? *

Do you consent to share Personal Health Info (PHI) WITH [VAGINAL STEAM FACILITATOR BRIT MANOR], and release liability for any claims, demands, injuries, damages, actions or causes of action to YOUR person or property arising out of or connected with the Products AND Services [of manor of living]?

E-Signature to Agree *

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Last

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