5 Koshas LLC Health Information Form PRENATAL YOGA
This information is kept confidential
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Emergency Contact and Phone number
Are you new to 5 Koshas Yoga and Wellness?
Number of weeks pregnant today
Number of pregnancies including this one
Number of deliveries
Do you have children? If so, what are their ages?
Have you practiced yoga before?
If yes, how long and what style of yoga?
Do any of the following conditions apply to you? (check all that apply)
Carrying Twins of Multiples
Diabetes or Gestational Diabetes
Elevated Blood Pressure
High stress or anxiety or panic attacks
History of Depression or Postpartum Depression
Limb numbness upon waking or carpal tunnel
Low back or Sciatic Pain
Previous Premature Labor
Sleep issues - if so please explain below
Tension headaches or migraines
Vaginal bleeding during pregnancy
Other - please explain below
Use this area to explain any answers above
Please provide any information about movement restrictions, other medical conditions, pain or injuries
Please list any medications that you are currently taking
What do you do for work? Do you get tension or pain in your body from work activities?
What are your hobbies and what do you do to stay active? Do any of these activities create any tension or pain in your body?
What benefit would you like to gain from this yoga class?
How did you hear about our classes?
Health care professional
Please check interests for you or your family:
Feldenkrais Awareness Through Movement
Outdoor/Rib Mountain Yoga
Strength Training Yoga
Stress Relief Yoga
Yoga Philosophy & Sutras Study
Yoga Teacher Training
Should be Empty: