5 Koshas LLC Health Information Form PRENATAL YOGA
This information is kept confidential
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact and Phone number
Are you new to 5 Koshas Yoga and Wellness?
Yes
No
Class Location/Time:
Due Date
-
Month
-
Day
Year
Date
Number of weeks pregnant today
Number of pregnancies including this one
Number of deliveries
Previous Cesarean
Yes
No
Do you have children? If so, what are their ages?
Have you practiced yoga before?
Yes
No
If yes, how long and what style of yoga?
Do any of the following conditions apply to you? (check all that apply)
Abdominal Weakness
Anemia
Carrying Twins of Multiples
Diabetes or Gestational Diabetes
Elevated Blood Pressure
Heartburn/reflux
Hemorrhoids
High stress or anxiety or panic attacks
History of Depression or Postpartum Depression
Incompetent Cervix
Joint Problems
Limb numbness upon waking or carpal tunnel
Low back or Sciatic Pain
Nausea
Placenta Previa
Previous Premature Labor
Sleep issues - if so please explain below
Tension headaches or migraines
Vaginal bleeding during pregnancy
Varicose Veins
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?
Background:
Health care professional
Educator
Please check interests for you or your family:
Acupuncture/Oriental Medicine
Beginner Yoga
Belly Dancing
Chair Yoga
Chant/Kirtan/Music
Events/Retreats/Workshops
Feldenkrais Awareness Through Movement
Gentle Yoga
Intermediate Yoga
Martial Arts
Massage
Meditation
Men's Yoga
Nutrition/Ayurveda
Outdoor/Rib Mountain Yoga
Pilates
Prenatal/Postnatal/Family Yoga
Private Yoga
Sound Therapy
Strength Training Yoga
Stress Relief Yoga
Tai Chi
Therapeutic Yoga
Yoga Philosophy & Sutras Study
Yoga Teacher Training
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