Nutrition Services
Courses/Products
Yoni Steam Supplies
About
Blog
Contact
Nutrition Services
Courses/Products
Yoni Steam Supplies
About
Blog
Contact
Functional nutrition for fertility, menstrual cycle health, and PCOS
Thank you for purchasing a Custom Yoni Steam Herb Blend!
Please complete the form below to help me formulate the perfect herbal yoni steam blend for you!
If you haven’t yet purchased a custom herb blend, you can do so
here
.
Name
*
First Name
Last Name
Email
*
Your order or invoice number
*
You can find this on your receipt.
Tell me about yourself and what you want to achieve with your custom herb blend.
*
Be as detailed as possible.
Do you have any food or plant allergies or sensitivities?
*
Including corn, soy, dairy, grasses, etc.
Are you currently under age 13?
*
Yes
No
What is the average length of your last 4 periods?
What is the average length of your last 4 cycles?
*
Cycle day 1 is the first day of your period, then count the days until your period comes again. For example, if you get your period on January 1st and your period comes again on January 26th. You had a 25 day cycle. The first day of your period is whenver your flow is heavy enough to need a pad or tampon. If you have some spotting for a few days before your period comes, those days are part of the last cycle.
Is your menstrual cycle absent or missing for an unknown reason or because of birth control?
*
Yes
No
If you don't currently have periods, what is the reason?
Hysterectomy
Pregnancy
Postpartum
Postmenopause
Haven't Had First Period Yet
Depo-Provera Birth Control Shot
Oral Birth Control
IUD
I'm not sure -- they are absent
Other
Are you currently taking birth control pills?
*
Yes
No
Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?
*
Yes
No
Do you have a birth control arm implant (i.e. nexplanon)?
*
Yes
No
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?
*
Yes
No
Do you have an Essure insert?
*
Yes
No
Do you have fresh spotting between periods?
*
Yes
No
Have you had spontaneous heavy bleeding within the past 3 months?
*
Yes
No
Have you had two periods per month (i.e. a period every 2 weeks) in the past 3 months?
*
Yes
No
Do you have green or yellow vaginal discharge?
*
Yes
No
Sometimes
Do you have an infection characterized with a burning itch?
*
Yes
No
Sometimes
Do you have malodorous vaginal discharge?
*
Yes
No
Sometimes
Do you have herpes?
*
Yes, currently
Yes, in the past
No
Are you currently or historically prone to yeast infections?
*
Yes
No
Are you currently or historically prone to bacterial vaginosis?
*
Yes
No
Do you have any type of dry infection (without vaginal discharge)?
*
Yes
No
Sometimes
Do you have vaginal dryness?
*
Yes
No
Have you experienced hot flashes recently?
*
Yes
No
Have you experienced nightsweats recently?
*
Yes
No
Do you have an aversion to heat?
*
Yes
No
Do you radiate heat?
*
Yes
No
Are you actively trying to conceive?
*
Yes
No
Not currently, we plan to begin trying within the next year
Do you have Uterine Fibroids?
*
Yes, currently
Yes, in the past
No
Do you have cystic ovaries?
*
Characterized as one large cyst.
Yes, currently
Yes, in the past
No
Do you have polycystic ovaries?
*
Characterized as multiple small cysts on the ovary.
Yes, as seen on ultrasound
Yes, an assumption based on PCOS diagnosis
No
Do you have blocked tubes?
*
Yes
No
What is your general energy level?
*
You may select more than one.
Very keyed up, have trouble calming down and relaxing
Energetic during the day and able to rest easily
Tired during the day
Exhausted, have trouble getting the energy for day to day tasks
What is your general disposition like?
*
You may select more than one.
Tend to be anxious
Tend to be depressed
Tend to be worried
Tend to be happy
Tend to be sad
Tend to be excitable
Tend to be apathetic
Tend to be calm and peaceful
Do you experience cramps with your period?
*
Yes, minor
Yes, severe
No
Sometimes
Do you experience PMS with your period?
*
Yes, minor
Yes, severe
No
Sometimes
What is a typical period like for you?
*
Select as many as apply to accurately describe a typical period.
Pink spotting before period starts
Brown spotting before period starts
Light, scanty period flow
Heavy period flow
Moderate period flow
Clots smaller than a quarter
Clots larger than a quarter
Light pink bleeding
Brown, thick bleeding
Bright red bleeding
Short periods, 2-3 days total
Average periods 4-6 days total
Long periods 7+ days total
Is there anything else we didn't cover that you want me to know?
Would you like to receive weekly emails from me about nutrition, menstrual cycle health, and fertility?
*
You will be able to unsubscribe any time.
Yes
No
Are you interested in being a case study for yoni steaming?
*
As a case study I will follow along with your progress as you use the herbs over the next three months and write an article about how yoni steaming and herbal medicine have impacted your menstrual cycle health and fertility.
Yes
No thanks
Maybe, send me more details.
Disclaimer
*
Most of the side-effects reported while steaming are positive. Users have reported better sleep and lucid dreams, relaxation, decreased swelling in legs and feet, decreased abdominal bloating, slimmer waistline, increased libido and sexual sensation; increased vaginal nectar and fertility, decrease in breast soreness, fewer headaches, fewer PMS symptoms and improved emotional balance, increased circulation and energy, tingling feet, glowing skin, reduction in incidence of hormonal acne and increased lubrication and vaginal nectar, scar softening, tighter vaginal canal and harmonization with the moon cycle. WHAT TO EXPECT Steaming is a cleanse. Some of the possible signs the vaginal steaming is working is if you experience -- the urge to urinate while steaming, brown discharge after steaming, increased clots or cramps during the period, increased dry cramps, increased irregular vaginal discharge (white, green, thick, clumpy), emotional release, periods that come earlier or later than expected. All of these signs are a normal part of the cleansing process and these signs will go away once the cleanse is complete. Please note these changes and let Mollie know of these positive changes. BEST PRACTICES 1) Go to the bathroom directly prior to vaginal steaming. 2) Learn proper period care. Avoid tampon use and instead use cotton pads or period panties. The period is a uterine cleanse and if you support it the clots can easily clear out. Plugging up with tampons, on the other hand, prevents the old residue from clearing out and that is often the cause of cramping. CAUTION SIGNS If steaming causes a rash, bumps, headaches itchiness, diarrhea or the onset of fresh spotting or inter-period bleeding, this could be a sign that your steam protocol or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur please let Mollie know so I can adjust the steam session as necessary or make a referral. **** In 99% of all cases using a mild steam session and mild herbs will prevent any of the above signs from happening so it's very important that you give honest answers in this intake form so that Mollie can provide you with the best herbal blend for your needs. I understand that vaginal steaming may have positive or negative side effects as a result of doing a vaginal steam session. I accept legal responsibility for my choice to do a vaginal steam session and waive the responsibility of Mollie Williams and Parsley and Pumpkins Nutrition in the case that any of the named side effects (or others) may occur. I agree that this is a legally binding document. My printed name and date below represent my signature.
First Name
Last Name
Thank you!
