Instagram
Facebook
(470) 591-2674
(470) 278-1111
Search
Your cart
0
No products in the cart.
Subtotal:
$
0.00
View Cart
Checkout
Jewells Are Forever Spa
Affordable, Beautiful, Relaxing and Holistic Spa
Home
About
Book Service
V-Steams
Sauna Sessions
Buy Products
Services Pricing
Client Forms
Intake Forms
Client Waiver Form
FAQ
Contact
Menu
back
Intake Forms
You are here:
Home
Intake Forms
Please enable JavaScript in your browser to complete this form.
Name
*
Current Age
*
Email
*
1. What vaginal steam setup are you using?
Jewell’s Are Forever vaginal steam sauna
I don’t have anything yet
I don’t have anything yet
Cycle Assessment
Please describe what your current period and cycle is like (i.e over the past 30 days). For example, if you don’t current have fibroids, but use to have them, then do not check that box. If you sometime have brown hesitant finish but didn’t have any this last period then don’t mark that box
2. Do you any sign of old residue buildup in the uterus? ( select all that apply)
Cramps
Cloths
Brown Menses
Hesitant Start (Brownish discharge at the beginning of period)
Hesitant Finish (Brownish discharge at the end of period)
Something like paint chips
If so please describe in more detail below
Do you any sign of poor circulation in the mid-section? (select all that apply)
Fibroids
Cysts
PCOS
Endometriosis
Uterine Pain
Ovulation Pain or Cramping
Abdominal Bloating
Restless Legs
If so please describe in more detail
Do you have any signs of excessive bacteria, yeast or mucus? (select all that apply)
Bacteria Infections
Blood Tinted Discharge
Foul Smelling Discharge or Menses
Sticky Menses
Thick Vaginal Discharge
Yeast Infections
Yellow Vaginal Discharge
If so please describe in more detail
Do you have any signs of excess heat and dehydration in the body? (select all that apply)
Night Sweats
Hot Flashes
Heat radiating from the bones
Constipation (less than a complete bowel movement everyday)
Thirst
Low Back Pain
Headaches
If so please describe in more detail
Do you have any signs of blood deficiency in the body? (select all that apply)
Light –colored menses from time to time ( pink, orange, yellow or clear)
Watery menses
Fresh red or light- colored spotting before or after period
Period that only last between one and three days
Fatigue
Headaches
Dry Skin
Anemia (currently or previously)
Absent Period
If so please describe in more detail
How many days long is your period (from first spot to last spot?
1-3
1-3
4
5-6
7 or longer
Describe in more detail
How long is your menstrual cycle ( the amount of days between period)?
31 days or longer
31 days or longer
27 days or shorter
28-30 days
It fluctuates-sometimes longer than 31 days , sometimes shorter than 27 days. It’s totally crazy
Please give us a little more detail:
Are you post-menopause and continue to experience phantom period symptoms, cramping, uterine pain, or vaginal dryness?
YES
YES
NO
If Yes please explain:
Are you trying to conceive?
YES
YES
NO
If Yes please explain:
Are you period absent for any unexplained reason?
YES
YES
NO
Do you have any pain during sex?
Are you period absent for any unexplained reason? (copy)
YES
YES
NO
Postpartum
Are you current postpartum
YES
YES
NO
Are you currently experiencing any of the following?
Cramps or contractions
Cramps or contractions
Infected tearing/stitches
Prolapse/hemorrhoids
Lochia
Spotting
Swelling
Loose skin
Postpartum Survey
What date(s) did you give birth?
Date-1 you give birth:
Date-2 you give birth:
After giving birth did you experience any of the following?
Contractions that continued 3 days or more after birth
Contractions that continued 3 days or more after birth
Excessive blood loss
Other….
Are you currently pregnant?
YES
YES
NO
Have you recently miscarriage?
YES
YES
NO
If yes please give more detail
Is there anything else about your health that you think might be relevant?
Do you have any questions or hesitations?
What is the main concerns that you are looking to address with vaginal steam therapy?
Submit
