Health and Interests Information - FOR PP CUSTOMERS

5 Koshas LLC Health Information Form POSTNATAL YOGA
This information is kept confidential
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / 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?

YesNo
Class Location/Time:
Baby's Name

First NameLast Name
Date of Birth

MonthDayYear
Number of weeks postpartum today
Type of delivery

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

YesNo
What are the current restrictions on movement given to you by your doctor, midwife, Doula
Any bleeding with acitivity

YesNo
If yes, explain further
Do you have diastasis recti (separation of abdominal muscles)

YesNo
If yes, current activity restrictions
Any other pain in body

YesNo
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 WeaknessAnemiaDiabetes or Gestational DiabetesElevated Blood PressureHeartburn/refluxHemorrhoidsHigh stress or anxiety or panic attacksHistory of Depression or Postpartum DepressionIncompetent CervixJoint ProblemsLimb numbness upon waking or carpal tunnelLow back or Sciatic PainNauseaPlacenta PreviaPrevious Premature LaborSleep issues - if so please explain belowTension headaches or migrainesVaginal bleeding during pregnancyVaricose VeinsOther - 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?

YesNo
If yes, how long and what style of yoga?
How did you hear about our classes?
Background:

Health care professionalEducator
Please check interests for you or your family:

Acupuncture/Oriental MedicineBeginner YogaBelly DancingChair YogaChant/Kirtan/MusicEvents/Retreats/WorkshopsFeldenkrais Awareness Through MovementGentle YogaIntermediate YogaMartial ArtsMassageMeditationMen's YogaNutrition/AyurvedaOutdoor/Rib Mountain YogaPilatesPrenatal/Postnatal/Family YogaPrivate YogaSound TherapyStrength Training YogaStress Relief YogaTai ChiTherapeutic YogaYoga Philosophy & Sutras StudyYoga Teacher Training
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5 Koshas LLC Health Information Form POSTNATAL YOGA