Name

First Name

Last Name

Have you practiced yoga pre pregnancy?

You do not need to have done yoga before do participate in my program, but this helps me understand how I can ensure the class has variations and options that best meet your physical needs.

If so, how would described your practice? Regular, adhoc etc.?

This question is trying to understand if your advanced in your practice (and therefore your body is able to do a stronger practice), a beginner or somewhere in between.

How would you describe your fitness levels?

As a guideline/benchmark to assist you with this response, it is recommended that pregnant women do up to 30 minutes moderate exercise a day.

Do you have any health circumstances related to this post birth injuries or complications that you need to disclose with me?

Examples of conditions that require adjustment and special attention in yoga class include diastases recti, gestational diabetes, sacral or pelvic pain e.g. pubic symphysis dysfunction, high blood pressure, preeclampsia, carpel tunnel etc.

Are you experiencing pelvic pain?

Have you seen a pelvic floor physiotherapist/received therapy on your pelvic floor?

Do you lose your balance easily or experience any dizziness?

Can you please tell me any past surgeries, injuries you have experienced?

Are you experiencing any head/neck issues?

Examples include jaw clenching, jaw pain, headache, neck pain.

Are you experiencing any back ache? Upper/mid/lower etc.

Are you experiencing any shoulder pain?

Are you experiencing any hip pain/tension?

Are you experiencing/have you had any of the following conditions:

Carpel Tunnel

Varicose Veins

Edema (swelling)

Knee or wrist joint issues

Bunion

Plantar fasciitis

Ankle pain/issues

What has been your main forms of exercise in past (childhood) and now in present?

What do you do to nurture yourself?

How much time are you willing/able to commit to train for your birth?

This question is not designed to make you feel bad about having little time, rather to understand what you are realistically able to do so we can develop a program that is going to meet you where you are as opposed to overwhelm you.

Do you have any specific goals in mind for working together?

What do you do for work and how do you spend your day (sitting at desk, sitting down alot, standing, walking alot, carrying a child etc.)

Enrolment Agreement

I hereby state that I am enrolling in this program at my own free will and with the understanding that this program is designed to teach me to use my own will and natural abilities to bring my mind and body into a state of positive wellbeing and health during pregnancy. I further understand that the content of classes is in no way intended to be represented as medical advice or as a prescription for medical procedure. Individuals should seek the advice of a health-care provider to answer any health-related or pregnancy-related issues surrounding their pregnancy, labour, birth or postpartum experience. I acknowledge and agree that I will in no way hold the instructor liable for any matter that may arise as a result of your use of our services in your pregnancy, labour, birth and postpartum experience. By selecting yes on this form, you indemnify Bella Mama against any claim any person may make against the instructor arising out of your use of our services.

Yes, I agree to the terms outlined.

No thank you I don't want to proceed.

PRENATAL BODY READY/YOGA SESSIONS INTAKE FORM

Info

Action