appleyoga Pregnancy Health Form

Registration form for pregnancy yoga students All information will be treated in the strictest confidence = Required Name     House Name or Number Street Name Town or City County or State Post Code Country     Work Phone Number Home Phone Number     Work Email Address Home Email Address     Occupation Date of Birth     Date of First Yoga Class     Due Date Planned Place of Birth Midwifery Practice     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?