Mums and Bubs Yoga Registrations

Your name (required)

Your phone number (required)

Address

Your email (required)

Occupation

Date of birth

MEDICAL HISTORY

Have you had any major surgery? If so what & when?

Please give details of any injuries, fractures, dislocations and how long ago.

Do you have any of the following?
HIGH or LOW BLOOD PRESSUREHEART PROBLEMSASTHMAARTHRITISCARPAL TUNNELNECK PROBLEMSBACK PROBLEMS (including Pubic Symphisis pain and/or Sacroiliac pain)ABDOMINAL SEPARATIONPELVIC FLOOR WEAKNESSOTHER (please specify below)

OTHER

ABOUT YOUR PREGNANCY / DELIVERY

How many weeks postpartum are you?

Was this your first pregnancy? YESNO

Please share your baby’s name:

Please share your baby’s gender:

Was your previous birth: C-SECTIONVAGINAL

Was your previous birth: EARLYLATEPREMATURE

Did you experience any complications pre/post delivery? (Please specify)

YOGA EXPERIENCE

Have you practiced yoga before? If so, for how long and where / what kind?

What is it you would like to get out of yoga?
RELAXATIONSTRESS MANAGEMENTFLEXIBILITYSTRENGTHRELIEF FROM BACK or NECK PAINOTHER (please specify below)

OTHER

How did you find out about these classes?

AGREEMENT

I understand that the instructions given throughout classes are intended only as a guidance. It is therefore my responsibility to:
1. Adjust my practice according to my limitation to ensure no personal injury occurs.
2. Inform the teacher before the class of any recent change to my physical condition.

I hereby declare that by submitting this form I release Danielle Mondahl and Thai Yoga Massage by Dani of any responsibility for any injury sustained and that I will take full responsibility for myself during the yoga classes.