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Yoni Steam
Benefits of Yoni Steaming
Common Questions
What to Expect At Your Appointment
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Home
Main Street Barber & Beauty - "Rent A Booth"
Meet the Stylists/Barbers
Yoni Steam Queen
Yoni Steam
Benefits of Yoni Steaming
Common Questions
What to Expect At Your Appointment
Book a Yoni Steam
Yoni Products
Photo Gallery
Name
*
First Name
Last Name
Address
*
Please enter your address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Subject
*
Message
*
Facebook Name
*
Occupation
*
Age
*
Date of Birth
*
How did you hear about us?
*
Refer Someone
Refer someone and you will be registered for a FREE steam!
First Name
Last Name
Referral's Number
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Numnber
*
Reasons for Visit (Check One)
*
Trying something new
Curious
Spiritual experience
Holistic healing
Just for fun
Relaxation
What are your intentions/expectations for this visit?
*
What are your major complaints or conditions you want to improve?
*
When did you first notice major complaints?
*
What brought it on?
*
Has there been a medical diagnosis?
*
Yes
No
By whom?
*
Physicians name
REPRODUCTIVE HEALTH HISTORY
What was the first day of your last period?
*
Has your period stopped - when?
*
How often does your periods come?
*
How many days does it last?
*
Any episodes of Amenorrhea (an abnormal absence of menstruation)?
*
Please list when and for how long
Do you have any concerns about your menstrual cycle?
*
Yes
No
Are you under treatment for infertility?
*
Yes
No
Describe current infertility treatment: (I.V.F, I.U.I, etc)
Describe past infertility treatments:
PREGNANCY HISTORY
Are you pregnant or trying to conceive e a child?
*
Yes
No
How many pregnancies have you had?
Complications with pregancies?
Yes
No
How many terminations and when was the last one?
How many miscarriages and when was the last one?
Number of Deliveries
*
DELIVERIES
Please put the delivery birth dates, infants name, gender and whether there were any complications.
Birth Date
MM
DD
YYYY
Infant Name
Gender
Male
Female
Complications
Yes
No
Check all that apply
*
Abnormal Pap Smears
Adhesions / Scar Tissue
Anxiety
Bladder Infections
Bloating / Water Retention
Cancer especially of the reproductive area
Chronic Miscarriage
Clotting
Dark Blood at beginning or end of cycle
Depression
Edema in legs
Endometriosis
Excessive Bleeding
Failure to Ovulate
Frequent Urination
Headaches or Migraines with period
Heaviness in Pelvis with period
Hemorrhoids
Hot Flashes
Incontinence
Infertility / Fertility Issues
Irregular Cycles (early or late)
Irregular Ovulation
Irritability
Low Back Pain with period
Low Libido
Mood Swings
Ovarian Cysts
Painful Intercourse
Painful Periods
PMS
Polycystic Ovarian Syndrome (PCOS)
Restless Legs
Sexually Transmitted Disease
Spotting
Uterine Fibroids
Uterine Infections
Uterine Polyps
Uterine Prolapse
Vaginal Discharge
Vaginal Dryness
Vaginal Infections
Varicose Veins
Womb Trauma
What forms of birth control do you use?
Do you have or have had in the past, the following:
Please check all that apply
WHEN YONI STEAMS SHOULD BE AVOIDED
IF YOU ARE PREGNANT OR THERE IS A POSSIBILITY OF PREGNANCY DURING OR AFTER OVULATION IF YOU ARE TRYING TO CONCEIVE 2 DAYS BEFORE MENSTRUATION. WAIT 2 DAYS AFTER MENSTRUATION STOPS WITH ANY OPEN WOUNDS, SORES,BLISTERS OR STITCHES IN VAGINAL AREA IF YOU HAVE A VAGINAL INFECTION OR FEVER PIERCINGS WILL NEED TO BE REMOVED
CAUTION
I DO NOT have an IUD (intrauterine device (IUD) is a little, t-shaped piece of plastic inserted into the uterus to provide birth control)
By signing here you agree you DO NOT have an IUD
*
If not applicable, put N/A
CAUTION
I DO have an IUD (intrauterine device (IUD) is a little, t-shaped piece of plastic inserted into the uterus to provide birth control) Steams help release matter from the uterus. To date, there are no incidents of IUD's being released with vaginal steam baths. They are on the caution list but no longer a reason to not vaginal steam due to the harm that it would cause the patient. However, I will ask that if you have an IUD, you sign below this paragraph as a release that you are aware of the possibility of your IUD releasing.
By signing here you agree you DO have an IUD
*
If not applicable, put N/A
PLEASE READ
I do currently have an IUD and have read the above paragraph and I understand that it is a possibility that my IUD could be released or shifted/moved due to the vaginal steam bath. I understand that I am having this vaginal/yoni steam bath at my own risk and hereby release Yoni Steam Queen, Main Street Barber and Beauty Salon and/or Diana Thomas of any and all liability.
Please sign here
*
Today's Date
*
MM
DD
YYYY
Please take a moment to read the following information and sign your full name bellow.
If you have a specific medical condition or specific symptoms, vaginal/yoni steam baths may be harmful to you. A referral from your primary care provider may be required prior to service being provided.
I undestand the following and by signing my name below I agree that:
If you have a specific medical condition or specific symptoms, vaginal/yoni steam baths may be harmful to you. A referral from your primary care provider may be required prior to service being provided.
Sign Here
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Thank you!
