Form

Bellies & Bubs Restorative Yoga Form
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State

Postal code
Mobile Number
Please enter a valid phone number.
Date of Birth

Month Day Year
How long has it been since you gave birth?

8wks - 3 months 3 - 6 months 6-12 months 12+ months
Please tell me a little about your birth experience

Vaginal Birth Vaginal Birth with assistance Episiotomy, tearing, vacuum or forceps Vaginal Birth requiring manual removal or placenta or transfusion from PPH Caesarean Birth
Do you have any of the following conditions

High blood pressure Low blood pressure Thyroid Imbalance - Hashimotos, Graves History of DVT's, clotting Other Autoimmune Deficiencies Anaemia Scoliosis or other spinal imbalances Ab Separation or Herniation from pregnancy, still quite Pelvic Floor Dysfunction Headaches/Migraines
What are you needing most from your Restorative Yoga practice?
Are you open to Reiki/Energy healing as part of your Restorative practice?
PLEASE READ CAREFULLY
Your teacher should be informed before class of any recent injury or illness. Yoga is safe and beneficial for mother and baby, when
practiced CONSCIENTIOUSLY and CONSCIOUSLY. Every possible care will be taken by your teacher to ensure your wellbeing and
safety, but she cannot be responsible for improper practice at any time. As a student of Yoga, it is important that you realize your
responsibility to yourself, by being aware of your personal limitations, therefore it is necessary to sign the following:
AGREEMENT
I understand that the instructions given throughout the classes are intended only as guidance. It is therefore my own responsibility
to adjust my practice according to my limitations to ensure that no personal injury occurs. I hereby declare that I take full
responsibility for myself during the classes. I also understand the importance of correct guidance and undertake not to pass on, nor
teach any of the Yoga and other techniques taught in class, other than for my own individual home practice, without the full
understanding of the proper use of Yoga.
Signature (typed/written)
Date

Month Day Year
Should be Empty:

Bellies & Bubs Restorative Yoga Form