Pregnancy Yoga Registration Form

    Personal Details

    Your Name

    Your Email

    Your Date of Birth

    Your Phone

    Your Address

    Your Occupation

    Medical History

    1. Have you had any major surgery?
    If so what and when?

    2. Please give details of any injuries,
    fractures, dislocations and how long ago.

    3. Do you have any of the following?

    High Blood PressureLow Blood PressureHeart ProblemsAsthmaArthritisCarpal TunnelNeck ProblemsBack ProblemsOther (please specify below)

    Your Pregnancy

    1. How many weeks pregnant are you?

    What is your approximate due date?

    2. Do you have a history of miscarriage?

    YesNo

    If yes, how many times have you miscarried?

    3. Is this your first baby?

    YesNo

    If you have had a baby before, what kind of birth did you have?

    C-SectionVaginal

    Was your birth ...
    EarlyLatePremature

    4. Are you experiencing any complications in your pregnancy?

    YesNo

    If yes, please specify below:

    5. Do you suffer from any of the following?

    Morning SicknessBleedingBreathlessnessFluid RetentionLeg CrampsAching HipsVaricose VeinsBack PainHeart BurnNauseaInsomniaHeadachesConstipationDizzinessSciaticaAnaemiaOther (please specify below)

    Your Yoga Experience

    1. Have you done yoga before?

    YesNo

    If yes, for how long, where and what kind?

    2. What would like to get out of yoga?

    RelaxationStress managementStrengthRelief from back painRelief from neck painBirth preparationSocial InteractionOther

    3. Any further requests, special needs or concerns?

    4. How did you find out about Professional Yoga?

    Agreement

    I understand that the instructions given throughout classes are intended only as a guidance. It is therefore my responsibility to 1. Adjust my practice according to my limitation to ensure no personal injury occurs 2. Inform the teacher before the class of any recent change to my physical condition.

    I hereby declare that I release Professional Yoga of any responsibility for any injury sustained and that I will take full responsibility for myself during the yoga classes.

    I accept the agreement above.

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