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Birth Doula
Yoga
Pregnancy Yoga
Mums & Bubs Yoga
Yoga Retreat Day
Yoga Therapy & Private Yoga
Massage
Thai Yoga Massage
Pregnancy Massage
Thai Foot Reflexology
Hens Parties and Girls Weekends
Gift Vouchers
Training
Thai Yoga Massage Level 1
Thai Yoga Massage Level 2
Advanced Thai Yoga Massage Techniques
Thai Yoga Massage for Pregnancy
Pregnancy Yoga Teacher Training
Couples Thai Massage Training
Thai Yoga Massage Taster Workshop
Thai Foot Reflexology Training
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Mums and Bubs Yoga Registrations
First name
Last name
Email
Phone number
Address
Occupation
Date of birth
MEDICAL HISTORY
Have you had any major surgery? If so what & when?
Please give details of any injuries, fractures, dislocations and how long ago.
Do you have any of the following?
High or low blood pressure
Heart problems
Asthma
Arthritis
Carpal Tunnel
Neck problems
Back problems (including Pubic Symphisis pain and/or Sacroiliac pain)
Abdominal separation
Pelvic floor weakness
Other (please specify below)
Other
Dietary Restrictions
ABOUT YOUR PREGNANCY / DELIVERY
How many weeks postpartum are you?
Please share your baby’s name:
Please share your baby’s gender:
Was this your first pregnancy?
Yes
No
Was your previous birth:
C-Section
Vaginal
Was your previous birth:
Early
Late
Premature
Did you experience any complications pre/post delivery? (Please specify)
YOGA EXPERIENCE
Have you practiced yoga before? If so, for how long and where / what kind?
What is it you would like to get out of yoga?
Relaxation
Stress Management
Flexibility
Strength
Relief from back or neck pain
Other (please specify below)
Other:
How did you find out about these classes?
AGREEMENT
I understand that the instructions given throughout classes are intended only as a guidance. It is therefore my responsibility to adjust my practice according to my limitation to ensure no personal injury occurs; and inform the teacher before the class of any recent change to my physical condition.
I hereby declare that by submitting this form I release Dani Mondahl of any responsibility for any injury sustained and that I will take full responsibility for myself during the yoga classes.
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