Pregnancy - Enrolment Form

If you are interested in attending a course or yoga day, please complete this form before the first class. Thanks!

Today's Date

Name of Course

Course Fee 

Payment status:

Paid / Unpaid

 

Students are ultimately responsible for their own health and well being, but knowing a few details about you helps us to teach appropriately, lets us know when we may need to adapt practices and gives us a chance to introduce practices of particular benefit to you.

All information written on this form is kept in strictest confidence. It is important to let the yoga teacher know if any of the below changes during the yoga course.

 

Name

Phone 

Mobile 

Address 

Date of Birth 

 

Have you ever practised yoga before?

If so for how long approximately?

And how recently?

 

Baby's due date?

Number of previous births?

Number of previous pregnancies?

Any miscarriage in the last two years?

 

If possible say why you are coming to yoga class. e.g. relaxation, increased flexibility, health, concentration etc.

 

Do you suffer from any illness, condition or physical disability? If so please give details.

 

Have you suffered any injury or undergone an operation in the last two years? If so please give details.

 

Do you have any of the following? (Tick relevant conditions and give a brief history below):

High blood pressure

Low blood pressure

Back problems, or history of . . .

Vaginal bleeding

Varicose veins

Morning sickness

Pre-eclampsia

Glaucoma

Epilepsy

Diabetes

Asthma

 

Brief History

 

Do you have any other physical, mental or emotional condition/s that may affect you during class?

 

Are you prescribed any medication? Please give brief details.



All information you give us will be treated in the strictest of confidence.