Prenatal 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 PROBLEMSOTHER (please specify below)

OTHER

ABOUT YOUR PREGNANCY

How far in your pregnancy are you (weeks)?

Your approximate due date:

Do you have a history of miscarriage? YESNO

If so, once or multiple times? ONCEMULTIPLE TIMES

Is this your first baby? YESNO

If no, was your previous birth: C-SECTIONVAGINAL

Was your previous birth: EARLYLATEPREMATURE

Are you experiencing any complications in your pregnancy? (Please specify)

How about common complaints?
FLUID RETENTIONLEG CRAMPSACHING HIPSHEART BURNNAUSEAINSOMNIAOTHER (please specify below)

OTHER

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 PAINBIRTH PREPARATIONOTHER (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.