Yoga Health Form

Name*

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState

Post Code

Mobile Number*

E-mail*

Occupation

Marital Status

Sports/Activities/Hobbies

Injuries/Illnesses/Accidents

Spinal Disorders (Scoliosis, Spondilosis, Herniated discs)

Infection/Contagious Diseases/Allergies

Have you had Covid or RSV/Influenza A in the past 2 weeks? Are you still symptomatic?

Surgeries (include Caesareans)

Have you done yoga before?

What is your level of yoga experience?

How many weeks pregnant are you?

Who is your Careprovider? (Midwife, Ob/Gyn, GP, Doula)

Are you on any of these medications?

Please list any other medications or natural supplements

If you’ve had any of the following blood tests or procedures in the 48hrs leading up to attending your session, please list

Please select any symptoms, or conditions below that are relevant to you.

A refreshment is provided at the Empowered Pregnancy Yoga workshop/Retreat; if you have any specific dietary requirements, please list below:-

YOUR PART OF THIS FORM IS NOW COMPLETE. THANK YOU FOR PROVIDING INFORMATION ABOUT YOUR PREGNANCY, ALL OF WHICH IS PRIVATE AND CONFIDENTIAL AND ENABLES ME TO BEST SUPPORT YOU, WITH CARE, COMPASSION AND NON-JUDGEMENT

PLEASE GO TO THE BOTTOM OF THE FORM, SIGN, DATE & SEND.

THANK YOU!

Have you given birth anytime in the 8-10 weeks leading up to attending your Session? If so, was your baby born by caesarean? Are you currently breastfeeding?

Are you taking any medications or supplements? Please list below

Please select any symptoms, or conditions below that are relevant to you.

What timeframe would you place yourself in, in terms of your parenting journey (based on the age of your youngest child)?

A refreshment is provided at the Zen Mumma Restorative yoga sessions; if you have any specific dietary requirements, please list below:-

The Zen Mumma Restorative Yoga (non pregnant) session includes gentle Reiki, to deepen the relaxation. However, if this is not for you, please just let us know.

YesNoUnsure, need more information

YOUR PART OF THIS FORM IS NOW COMPLETE. THANK YOU FOR PROVIDING INFORMATION ABOUT YOUR PREVIOUS PREGNANCY, BABY (IES) BIRTH(S) & PARENTING JOURNEY, ALL OF WHICH IS PRIVATE AND CONFIDENTIAL AND ENABLES ME TO BEST SUPPORT YOU, WITH CARE, COMPASSION AND NON-JUDGEMENT

PLEASE NOW SIGN, DATE & SEND.

THANK YOU!

PLEASE READ CAREFULLY

Yoga is both safe and beneficial when provided under the guidance of an experienced Practitioner, who is made fully aware of any high risk factors in your pregnancy or postpartum period and can therefore adjust your yoga practice accordingly.

Every possible care will be taken by your Therapist to ensure your wellbeing and safety. It is important that you realise your responsibility to yourself and your baby (if pregnant), by being transparent with any risk factors, injuries or illnesses that may arise at any time during or between sessions.

AGREEMENT

I understand that any recommendations and guidance provided during my class practice are intended only as guidance and an invitation to work within my personal comfort and limitations.

It is my own responsibility to adjust any additional stretches or techniques as recommended as part of my practice, to my level of capabilities and limitations to ensure that no personal injury occurs. I hereby declare that I take full responsibility for personal well-being.

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Yoga Health Form

PLEASE COMPLETE THIS SECTION WHETHER PREGNANT, OR NOT

PLEASE ONLY COMPLETE THIS SECTION IF PREGNANT

PLEASE ONLY COMPLETE THIS SECTION IF NOT PREGNANT