Postnatal (Mum + Baby) Yoga Health Questionnaire

Name of Mother + Baby

Email Address

Baby's Date of Birth

Do you have older children? Do you have older children? Yes

What are their ages?

Nature of this most recent birth: Nature of this most recent birth: Self-starting labour Medical Induction of labour Accelerated labour Vaginal Ventouse Forceps Caesarean

Delivery environment: Delivery environment: Hospital Birth Centre Home

Any drugs administered during labour? Any drugs administered during labour? Gas + Air Pethedine Epidural Other

Any stitches required following tearing / episiotomy ? Any stitches required following tearing / episiotomy ? Yes

At what gestation was your baby born?

Since the birth of this baby have you experienced any of the following? Since the birth of this baby have you experienced any of the following? Sacro-iliac pain Back pain Sciatica High Blood Pressure Anaemia Depression Anxiety Prolonged Bleeding Exhaustion

Were you working with any injuries / health issues Prior to pregnancy?

Are you taking any medication that may affect your yoga practice?

Is there anything else you would like me to know?

Client Declaration: As far as I am aware, I have disclosed to my yoga teacher all information regarding my health relevant to the practice of yoga. I take full responsibility for all applications of yoga I practice in the class and outside the class. I fully understand that the recommendations, ideas or techniques expressed and described cannot be regarded as substitute for the advice of a qualified medical practitioner. Any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk. Client Declaration: As far as I am aware, I have disclosed to my yoga teacher all information regarding my health relevant to the practice of yoga. I take full responsibility for all applications of yoga I practice in the class and outside the class. I fully understand that the recommendations, ideas or techniques expressed and described cannot be regarded as substitute for the advice of a qualified medical practitioner. Any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk. Tick as signed declaration