Pregnancy Yoga Health Questionnaire

Pregnancy Yoga Health Questionnaire

Please complete the form to the best of your knowledge and be assured that it will be treated in the strictest confidence. The questionnaire is designed to make sure that you and baby can practice safely. If there is anything you are unsure about or would like to chat through, please get in touch.

Before you fill out this questionnaire and send the form back to Nurtured Soul, we advise you read the privacy policy so you understand and accept what happens to your data. By you forwarding the questionnaire on to us, we will assume you accept the privacy policies stated.

Please fill out the following form.

First name

Last name

Address

Date of birth

Occupation

Email

Phone

Preferred Contact

Email

Phone

Emergency Contact Information; Full name / Date of birth / Address / Email / Phone number / Relationship to you

Estimated due date

Number of weeks pregnant

Pregnant with twins

Yes

No

Low/high risk pregnancy If high risk, please state why

During this pregnancy what are you currently experiencing? (please tick those that are affecting you right now)

Is there anything that concerns you or that you would be interested in?

Is there anything you would like me to know about?

Have you had a major injury in the last 5 years? If yes please give more details in the section below that says 'more details'

Yes

No

Are you taking any prescribed medication? If yes please give more details in the section below that says 'more details'

Yes

No

Are you receiving any treatment for diagnosed medical conditions? If yes please give more details in the section below that says 'more details'

Yes

No

Have you had any recent operations? If yes please give more details in the section below that says 'more details'

Yes

No

If yes to any of the above, please give more details here....

Medical conditions separate to the pregnancy

Whilst yoga may be practised safely by most people, there are certain conditions which require special attention. If you are unsure, please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical condi

I declare that the info I’ve provided is accurate and complete.

Please let me know what aspects of pregnancy yoga you are interested in?

Declaration

Please tick if you agree with this statement

By ticking this box, I declare that I have disclosed to my yoga teacher all information regarding my health relevant to the practice of yoga during my pregnancy. I take full responsibility for all applications of yoga I practice in & outside the classes during my pregnancy. I fully understand that the recommendations, ideas or techniques expressed & described in the pregnancy yoga classes cannot be a substitute for the advice of a qualified medical practitioner & is at my sole discretion & risk.

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