Name
*
First Name
Last Name
Address
Email
*
Phone
Let's determine the length of your cycle. This would be the amount of days from day one of the menstruation to the start of the next menstruation. Women commonly report that their cycle is 28 days but it is rare for the cycle to always be 28 days. It usually fluctuates and looking at the variations in length can reveal important information about your overall health. In order to get a proper determination of your cycle length please list the length of your past 6 cycles. If you use a period app it automatically calculates this information for you. If you do not use a period app, you can use the calendar where you mark down your periods. Count from day one of the period until the day before your next period starts. That'll be the overall cycle length. If you do not use an app or calendar please leave the form blank and use the notes section to write any info about how long you think it might be.
Please Select the First Day of Your Last Menstruation
*
MM
DD
YYYY
How long was your last cycle?
*
How long was your 2nd last cycle?
*
How long was your 3rd last cycle?
How long was your 4th last cycle?
How long was your 5th last cycle?
How long was your 6th last cycle?
What age were you when you had your first menstruation (menarche)?
*
NOTES
Each menstruation is a snapshot of your current state of health during this month. In general women's health can change significantly from cycle to cycle. For this reason it's very useful to look at the signs from your very last menstruation to see exactly what your signs tell us about your health at this moment in time.
Please fill out the following sections and mark:
- YES ONLY if that symptom occurred on your VERY LAST or current Menstruation.
- NO if you NEVER experienced this symptom
- Not the Last Period But Sometimes It Does Occur if it happens sometimes but didn't occur during the last or current menstruation
- Been a Long Time if it happened a while back like 6 months ago or more
Finally, there is a Notes section at the end where you can include any more information that you think might be relevant about these specific signs.
If you do not currently have a menstruation please do your best to fill out information about your last menstruation marking 'It's Been a Long Time'
There will also be some indicators and questions below that are not menstruation-related. Please answer those accordingly.
Two periods per month
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Fresh Spotting during Ovulation
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Spontaneous Bleeding
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Pre-Period Fresh Spotting Before Menstrual Cycle Day 28
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Short Menstrual Cycles (27 Days or Shorter)
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
NOTES
Menstrual clots
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Post-Period Brown Hesitant Finish
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Uterine Cramping During Period
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Uterine Cramping During Ovulation
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Shooting Pain in Uterus
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Pre-Period Brown Hesitant Start
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Brown Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Black Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Breast Soreness
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Endometriosis
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Pre Menstrual Disphoric Disorder
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Adhesions
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Polyps
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Have you had any abdominal surgeries or procedures that have created scar tissue or stagnation?
NOTES
Pink Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Orange Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Yellow Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Clear Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Absent Periods
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Menstruation Lasts Only 3 or Less Days
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Fresh Spotting But Period Never Comes
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Watery Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Anemia
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Fresh Spotting on Menstrual Cycle Day 28 or Later
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Fresh Spotting During Period Days 1-4 (instead of menses)
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
NOTES
Hot Flashes
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Neon Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Heavy Purple
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Infections
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Herpes Outbreaks
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Yeast Infections
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Bacterial Infections
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Urinary Tract Infections
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Burning Itch
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Human Papilloma Virus (HPV)
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Cervical Dysplasia
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Cancer
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Other STD (sexual transmitted diseases)
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Other Virus?
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Nightsweats
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
NOTES
Nightsweats
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Dried Blood Flakes
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Flaky Vaginal Discharge
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Constipation in General
*
yes
no
Constipation only During Menstruation
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Vaginal Dryness
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Chapped Skin
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Dry or Cracked Lips
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Itchy Skin
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
UTI (Urinary tract infection)
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
NOTES
Swelling
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Sticky Menses
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Yellow Vaginal Discharge
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Green Vaginal Discharge
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
White Vaginal Discharge
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Clumpy Vaginal Discharge
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Clear Bad-Smelling Discharge
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
PCOS (polycystic ovary syndrome)
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Fibroids
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Ovarian Cysts
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Bartholin's Cyst
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Nabothian Cyst
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Other Cyst?
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Malodor
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
NOTES
Nausea
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Abdominal Bloating
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Vomiting
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Loose Stools in General
*
yes
no
Loose Stools only During Menstruation
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Undigested Food in Stools
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
Food Intolerances
*
yes
no
Not the Last Cycle But Sometimes It Does Occur
Been a Long Time
NOTES
Let's do a quick little check list and see how your very last cycle compares to a standard healthy cycle. Please fill this out based on your last cycle.
What was the Menstruation Length (from first spot to last spot) of Your Last Menstruation?
What Was Your Last Cycle Length (from day 1 of menstruation to start of next menstruation)?
What Was Your Flow Like During Your Last Menstruation? (light, medium, heavy, flooding, start and stop, clotted, stringy)
*
What Menses Colors Did You Observe in Your Last Menstruation? (red, brown, black, pink, orange, purple, yellow, clear)
What Observations Have You Made About Your Vaginal Discharge Since Your Last Menstruation? (clear nectar, white, yellow, green, flaky, malodorous, clear and watery, clear with malodor, ammonia scent, sour scent)
*
What Menstrual Cycle Symptoms/Side Effects Did You Experience Before, During and After Your Last Menstruation? (back pain, headaches, fatigue, cramps, aches, swelling, nausea, vomiting, hormonal acne, night sweats, hot flashes, other?)
*
There are certain lifestyle behaviors and products that really help to improve overall menstrual cycle health. This is known as proper period care or how you take care of yourself during menstruation. Let's see how you're doing to pamper yourself.
Cotton Menstrual Pads
*
yes
no
Period Panties
*
yes
no
Nourishing Soups
*
yes
no
Herbal Teas
*
yes
no
Warm Water Bottle, Heating Pad or Blanket
*
yes
no
Go to Bed Early by 10pm
*
yes
no
Extra Naps and/or Full-body Rest
*
yes
no
Self-Care Prioritization
*
yes
no
Refrain from Sex
*
yes
no
Abdominal Massage
*
yes
no
Castor or Coconut Oil Packs (NOT during periods)
*
yes
no
Do you avoid Inversions and/or Exercise?
*
yes
no
Keep Warm and Cozy
*
yes
no
Let others take care of you during your menses
*
yes
no
What kind of Period Care do you use currently or have used in the last 3 months?
(tampons, cup, pads, period underwear, etc)
A healthy menstruation lasts for 4 days long of fresh bleeding. In order for the menstruation to stop on day 5 the body needs adequate rest during days 1-4 of the menstruation. Inadequate rest during days 1-4 of the menses can result in menses with 5 days or longer of fresh bleeding. Do You Have Any of the Following Signs of Inadequate Period Rest?
5 Days or More of Fresh Menstruation
*
yes
no
Heavy Menstruation
*
yes
no
Flood Bleeding
*
yes
no
Post-Period Fresh Spotting (Period Day 5 or Later)
*
yes
no
NOTES
Your Age
In what phase of your cycle are you at currently?
*
Menarche, mid-cycle life, approaching menopause, menopausal, postmenopause
Type of birth
Total Number of Pregnancy Losses?
*
Dates of losses and medical intervention involved
Are You Currently Pregnant?
*
yes
no
It's a Possibility
Are You Currently Trying to Conceive?
*
yes
no
If trying to conceive are you past this month's ovulation? Alternatively if using IUI/IVF has the transfer already taken place?
yes
no
NOTES
Do You Currently Have Active Fresh Bleeding or Fresh Spotting?
*
yes
no
Do You Currently Have an infection characterized with a Burning Itch?
*
yes
no
NOTES
What kind of Birth Control or Pregnancy Prevention Form do you use? Since when?
*
Do you have a Tubal Coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?
*
yes
no
I don't know
Have you had a Uterine Ablation Procedure (where the uterine walls are burned so they scar over)?
*
yes
no
I don't know
Have you had a Laparoscopy of the Uterus?
*
yes
no
I don't know
Do you have an Essure insert?
yes
no
I don't know
Have you Had Any Surgeries or Operations?
Do You Have Any Major Health Concerns?
Are you Taking Any Medications or Artificial Hormones?
What is Your Experience with Vaginal Steaming? (Please indicate if you have ever done it before. If you have done it please describe your experience, period changes, herbs and setup used and any questions or complications.)
Any Other Relevant Information?
If you forgot something important or want to add anything to your intake form, feel free to askdiana@steamylicious.com within 3 days of submission!
Client Name
*
First Name
Last Name
*
THIS AGREEMENT is made between steamylicious and Client (as typed in the field above) ("I") (collectively the “Parties”).
I have purchased or am receiving complimentary steaming services, products or a consultation from steamylicious (the "Products and/or Services").
I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in, or cause me to have an adverse reaction to, the Services, including but not limited to preterm pregnancy. I affirm, that all information provided to steamylicious by me is accurate and complete and I understand that failing to provide information may result in a greater risk of injury. I acknowledge that my purchase and participation in or use of the Products and/or Services is voluntary and I do so entirely at my own risk. I acknowledge that I have approval from my doctor or medical professional to use or receive the Products and/or Services or I yield that requirement and take responsibility for my own medical decision-making.
I understand that results may vary from person to person. I understand that I may react adversely to the Products and/or Services and they may result in injury to me. Side effects include, but are not limited to, rash, bumps, headaches, itchiness, diarrhea, increased vaginal discharge, cramping or the onset of fresh spotting or inter-period bleeding. If I elect to continue Products and/or Services after such results, I will alert steamylicious to issues so that the Products and/or Services may be adjusted, or a referral can be made. I expressly agree that all risk of injury that I undertake as a part of the Products and/or Services is undertaken at my sole risk.
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I will not rely on the Products and/or Services as an alternative to advice from my medical professional or healthcare provider and I will never delay seeking medical advice, disregard medical advice, or discontinue medical treatment as a result of any information provided before, during, or after the Products and/or Services. I understand and agree that all medical related information is for informational purposes only.
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I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during the Products and/or Services.
This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I UNDERSTAND AND AGREE THAT I AM GIVING UP LEGAL RIGHTS BY SIGNING THIS AGREEMENT AND THAT I AM DOING SO VOLUNTARILY, FREELY, UNDER NO THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE, OR GUARANTEE BEING COMMUNICATED TO ME. THE SIGNATURE BELOW IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW.
My printed name and date below represent my signature.
First Name
Last Name
Date of Signature
*
MM
DD
YYYY