Vagina Steam Intake Form
Sign in to Google to save your progress. Learn more
Untitled Question
Clear selection
Do you have a cough, fever (98 degree), or cold symptoms?
Clear selection
I understand I must wear a mask at all times.
Clear selection
Have you been around anyone with the symptoms above?
Clear selection
Name: *
Telephone: *
Has your vagina (womb) experienced any kind of physical trauma?
Clear selection
Do you have regular monthly menstrual cycles?
Clear selection
Do you have regular monthly menstrual cycles?
Abortions, Adrenal Fatigue, Amenorrhea, Clotting During Menses, Death of a Child, Endometriosis, Feminine Odor, Fibroids, Genital Itching, Hormone Imbalances, Infertility, Irregular Menses, Menopause, Menses longer than 4 days, Miscarriages, Ovarian Cysts, Painful Menses, PMS, Poly-cystic Ovarian Syndrome (PCOS), Pregnancy, Rape/Incest, Sexually Transmitted Diseases,  Spotting in Between Periods, Tumors, Use of Birth Control, Vaginal Discharge
What are you wanting from this v-steam?
What are your other health concerns? (Please list in order of severity) Yes
Please list dis-eases prevalent on both your mother and father sides of your family: (i.e. diabetes, high blood pressure, cancers) HP
What medications (prescribed or over the counter), herbs, vitamins, supplements, etc..., are you currently taking? (also list why you are taking them) MultiVitamins
Please list  any known contagious dis-ease at this time?
Liability Policy
The use of drugs, medication or alcohol prior to or during the Vaginal Detox Steam session may lead to dizziness or unconsciousness. Please consult your physician if you are in doubt of your ability to use the Vaginal Detox Steam for health reasons. Please discontinue the use of the sauna if you feel light-headed, dizzy or heat exhausted. Vaginal Detox Steam sessions should be limited to a maximum of 60 minutes. It is advisable to drink plenty of water before and after sauna session. It is advised not to eat at least one to two hours prior to your sauna session to avoid any ill feelings. Clients using any medications must consult a physician or pharmacist prior to the use of the sauna. Pregnant women should consult their physician prior to the use of the sauna. Excessive body temperatures have a potential for causing fetal damage during the early days of pregnancy. Do not use any chemicals or lotions prior to your sauna session. These items may block pores and affect perspiration. By checking the agreement box below, You acknowledge and accept the risks inherent in the use of the Vaginal Detox Steam session. You voluntarily assume the risk of injury, accident or death, which may arise from the use of the Vaginal Detox Steam session. You and any of your heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal injury or property damages of any kind sustained while in the Vaginal Detox Steam session, during the use of the Vaginal Detox Steam session and from any advice provided by an employee, independent contractor or any representative. By checking the box below you are stating " I agree that this intake form and Waiver is in effect for all Vaginal Detox Steam sessions and will not expire unless requested by either party".
By checking the box below you hereby agree to the above terms *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy