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Birth Doula
Yoga
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Thai Yoga Massage Level 1
Thai Yoga Massage Level 2
Advanced Thai Yoga Massage Techniques
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Couples Thai Massage Training
Thai Yoga Massage Taster Workshop
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Prenatal Yoga Registration Form
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
Other (please specify below)
Other
Dietary Restrictions
ABOUT YOUR PREGNANCY
How far in your pregnancy are you (weeks)?
Your approximate due date:
Do you have a history of miscarriage?
Yes
No
If so, once or multiple times?
Once
Multiple times
Is this your first baby?
Yes
No
If no, was your previous birth:
C-Section
Vaginal
Was your previous birth:
Early
Late
Premature
Are you experiencing any complications in your pregnancy? (Please specify)
How about common complaints?
Fluid Retention
Leg Cramps
Aching Hips
Heart Burn
Nausea
Insomnia
Other (please specify below)
Other:
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
Birth preparation
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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