Health and Interests Information - FOR PP CUSTOMERS

5 Koshas LLC Health Information Form POSTNATAL 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:
Baby's Name

First Name Last Name
Date of Birth

Month Day Year
Number of weeks postpartum today
Type of delivery

Vaginal Delivery C-Section
If vaginal delivery, any significant tearing or trauma to the perineum

Yes No
What are the current restrictions on movement given to you by your doctor, midwife, Doula
Any bleeding with acitivity

Yes No
If yes, explain further
Do you have diastasis recti (separation of abdominal muscles)

Yes No
If yes, current activity restrictions
Any other pain in body

Yes No
If yes, where?
Intensity of pain/discomfort
Frequency of pain/discomfort
Any concerns
Do any of the following conditions apply to you? (check all that apply)

Abdominal Weakness Anemia 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 list any medications that you are currently taking
Do you have children? If so, what are their ages?
What benefit would you like to gain from this yoga class?
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 do you do for work? Do you get tension or pain in your body from work activities?
Have you practiced yoga before?

Yes No
If yes, how long and what style of yoga?
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
Should be Empty:

5 Koshas LLC Health Information Form POSTNATAL YOGA