Prenatal Intake Form

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Thank you for your interest in private prenatal yoga sessions with me. In order to provide you with the most personalised yoga sessions, please complete the form below.

I am excited to work with you. If you have any questions, please do not hesitate to contact me.

PRENATAL INTAKE FORM

* Indicates required field

Name *

First

Last

AGE *

FULL ADDRESS *

Email *

EMERGENCY CONTACT *

HOW MANY WEEKS PREGNANT ARE YOU? *

WHAT IS YOUR DUE DATE? *

ARE YOU EXPECTING TWINS? *

If over 34 weeks (32 for twins), do you know your baby’s position? *

Is this your 1st birth? *

During this pregnancy, have you experienced any of the following? *

High Blood Pressure Low Blood Pressure Low Back Pain Pelvic Girdle Pain Dizziness Other

Have you informed your doctor/midwife that you are starting yoga? *

Yes No

Have you practiced yoga before, if so how long, what style? *

Yes No

PLEASE DETAIL YOUR EXPERIENCE OF PRACTICING YOGA *

What would you like to receive from your prenatal yoga practice? *

What other exercise are you doing in pregnancy, and how often? *

How did you hear about these classes? *

ARE YOU AFTER A 5 CLASS PACK OR A 10 CLASS PACK? *

I'll start with 5 classes and see how I go I'm all in and want 10 classes and a 10% OFF

Client declaration *
As far as I am aware, 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 the class and outside the class during my pregnancy. I fully understand that the recommendations, ideas or techniques expressed and described in these pregnancy yoga classes cannot be regarded as substitute for the advice of qualified medical practitioners. Any uses to which recommendations, ideas and techniques are put are at my sole discretion and risk.

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St Kilda, Melbourne VIC
[email protected]

Home
About
Privates + Prenatal
Corporate Yoga
Contact