I want to respond to you and your life situation individually. Therefore I would like you to fill in the following fields with all relevant information for me and our work together. All your statements are subject to confidentiality, which I treat with the utmost discretion. Based on your assessment, please answer the questions on the following pages truthfully. If you don't understand a question or need help, please don't hesitate to ask. In this questionnaire, there are a few technical terms that you may not be familiar with, so I would like to explain them briefly here: Lunar bleeding = menstrual bleeding / lunar cycle = menstrual cycle / cervical mucus = discharge

Name:

Date of Birth:

Address:

Telephone Number:

E-Mail:

Profession:

Relationship Status:

QUESTIONS ABOUT YOUR GENERAL HEALTH

How much sport do you do per week?

How do you nourish yourself?

How much water or unsweetened tea do you drink per day?

Do you take medication?

If YES, which?

Are you doing a yoni steam bath (Peristeam Hydrotherapy) for the first time?

Do you allow yourself rest during your period?

What products do you use during your period?

Do you have poor physical circulation (cold hands/feet)?

Do you have poor digestion (not daily or irregular)?

Do you regularly suffer from flatulence or a bloated stomach?

Are you having your moon bleeding (menstruation) right now?

Have you had spontaneous heavy bleeding in the last 3 months?

Are your moon cycles (menstrual cycles) always between 28 and 30 days long?

Is your moon bleeding:

Do you currently have spotting or bleeding between periods?

During your moon bleeding, do you have:

Is your moon bleed sticky or mucous/mucilaginous?

Are you pregnant?

Is there a possibility that you are pregnant?

Did your doctor ever notice that your uterine lining does not build up well or is generally very thin?

Do you suffer from endometriosis?

Do you suffer from adenomyosis?

Do you suffer from chronic endometritis?

Do you have:

Do you currently have an infection with burning itching?

Do you have problems with your kidneys?

Have you had hot flashes in the last month?

Have you had night sweats in the last month?

Do you often have a runny nose (unrelated to a cold or hay fever)?

Are you currently on birth control pills?

Do you use an IUD for contraception?

Do you use the Nuva Ring? If so, this should be removed prior to the steaming session.

Do you have an arm implant for contraception (Implanon NXT)?

Have you been fitted with the ESSURE IUD?

Have you had a uterine ablation (in which the walls of the uterus are burned off, causing it to scar)?

Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?

Are you missing your moon bleeding because of contraception?

Are you currently or have you been prone to yeast infections in the past?

Are you currently or have you been prone to bacterial vaginosis in the past?

Are you currently or have you been prone to urinary tract infections (bladder infections) in the past?

Do you have genital herpes?

In the past (3 months or more) have you had spontaneous bleeding or two moon bleeds per month?

Please provide more information about the answers you have ticked "yes" or "not sure" so far.

Is your lunar cycle missing or absent for some unknown reason?

If you don't have a moon bleeding, did you have the cause investigated and if so, what was the result?

Are your lunar cycles longer than 30 days?

Do you sometimes or always have a lunar cycle of 27 days or less?

Between your regular moon bleeding, do you have spotting or bleeding in between?

Do you have greenish cervical mucus (discharge)?

Do you have yellowish cervical mucus?

Do you have white cervical mucus?

Do you have thick cervical mucus (outside the ovulation phase)?

Do you have foul smelling/fishy cervical mucus?

Do you suffer from vaginal dryness?

Do you have dry cervical mucus or dry menstrual blood?

Do you have something like a dry vaginal infection (no discharge but e.g. with itching)?

Is the climate where you stay/live currently or mostly very hot?

Do you have an aversion to heat?

Does your body radiate heat?

Are you more of a hot-blooded or cold-blooded type?

Do you have any allergies e.g. food, plants, animals, house dust?

Are you prone to vaginal infections?

For all affirmative answers, please provide extensive information or necessary information that was not covered in the questionnaire (e.g. cancer, etc.)

All of the information you provide is subject to my confidentiality and will be treated with the utmost discretion.

MANDATORY

DESIRED PAYMENT METHOD

As a customer, I will inform 'Bloom' with every future escort as soon as basic information such as an address, e-mail or telephone changes. I have carefully read all pages of this questionnaire. I certify that I have answered all questions to the best of my knowledge, and I am not withholding any information that may be relevant to my treatment. I have pointed out chronic diseases and autoimmune diseases. I will discuss the questions for each visit with the therapist at 'Bloom' directly on the day of my appointment.

Peristeam Hydrotherapy is not a healing treatment or promise of healing. It does not replace a medical, psychological, psychotherapeutic examination or a midwife.

I expressly allow the storage of all information given here for analysis and advice that is mentioned in the data protection declaration.

With my signature I authorize the internal data processing as stated in the data protection regulations.

Date:

Signature

© Bloom (owner Johanna Rhode), Königsallee 39, 44789 Bochum / Analysis Consultation Form / History Document status: 01.01.2023 / Reproduction, copying and use of all content is not permitted without express written permission. Modification of the document is not permitted. The completed forms are kept by Bloom (owner Johanna Rhode) and are not passed on to third parties.