appleyoga Pregnancy Health Form

Registration form for pregnancy yoga students

All information will be treated in the strictest confidence

required field = Required

Name required field
   
House Name or Number required field
Street Name required field
Town or City required field
County or State
Post Code required field
Country
   
Work Phone Number required field
Home Phone Number required field
   
Work Email Address required field
Home Email Address required field
   
Occupation required field
Date of Birth required field
   
Date of First Yoga Class
   
Due Date required field
Planned Place of Birth required field
Midwifery Practice required field
   
Have you studied yoga before? Please give details of how long, what style of yoga etc.
Why have you come to learn yoga, and what do you hope to gain from it?

During this pregnancy, have you experienced any of the following?

Morning Sickness Constipation Nosebleeds Lower Back Pain Varicose Veins
High Blood Pressure Depression Bleeding Headaches Heartburn
Anaemia Sciatica Oedema (Swollen Joints) Pre-Eclampsia Anxiety
Fibroid Pain Dizziness Breathlessness Diabetes Aching Groin
Sleep Disturbance

Please give details of any of the above which you have selected, or any other health issues which you feel may have some bearing on your yoga practice
 
Prior to this pregnancy, have you suffered any injury or undergone any surgery (e.g caesarean section, knee surgery) that may have some bearing on your yoga practice?
Yes No
 
If so, please state details
 
Have you had any previous pregnancies?
Yes No
 
Have you had any previous miscarriages?
Yes No
 
Have you had any previous births?
Yes No
 
Do you smoke?
Yes No
 
Are you taking any form of medication that may have some bearing on your yoga practice?
Yes No
 
How did you hear about appleyoga classes?
required field