Pregnancy Yoga Health Questionnaire

Name

Email Address

What is your estimated due date?

How many weeks pregnant will you be at our first prenatal yoga class?

Is this your first pregnancy? Is this your first pregnancy? Yes No

Is your pregnancy classed as high risk? Is your pregnancy classed as high risk? Yes No

If your pregnancy is considered high risk, please explain why...

Prior to pregnancy, were you working with any injuries / health issues that might affect your practice?

Pregnancy Health Check (please tick those that are affecting you right now) Pregnancy Health Check (please tick those that are affecting you right now) Pubic pain / pelvic girdle pain High blood pressure Low Blood Pressure Morning Sickness Hyperemesis gravidarum Sciatica Oedema (swollen joints) Constipation Nosebleeds Anxiety Placenta Previa Carpal Tunnel Haemorrhoids Insomnia

Are you experiencing any other pregnancy related symptoms not listed above?

What aspects of pregnancy yoga are you interested in? What aspects of pregnancy yoga are you interested in? Breathing exercises Strengthening and toning muscles Relieving specific ailments Quiet time to bond with baby Relaxation / meditation Supporting good posture through pregnancy Preparing you body for birth

Any other reasons not listed above?

Is there anything else you would like me to know about?

Declaration - By ticking this box, I am declaring that I have disclosed to my yoga teacher all information regarding my health relevent to the practice of yoga during my pregnancy. Declaration - By ticking this box, I am declaring that I have disclosed to my yoga teacher all information regarding my health relevent to the practice of yoga during my pregnancy. Tick as signed declaration