Welcome to Pre/Postnatal Yoga! I am so glad you're here. To help me get to know you better and to intentionally plan sessions to YOU, please complete the below form.

Name

Cell Phone

Medical and Pregnancy History

Current Stage PrenatalPostnatal

Due Date/Baby's Birth Date

Is this your first pregnancy? YesNo

Any complications or concerns during this pregnancy or past pregnancies? If yes, please explain.

Are you experiencing any of the following? High Blood Pressure Gestational Diabetes Placenta previaPreterm labor risksOther (please specify below)

Other:

Delivery History

Please fill out the next few questions if you are currently postnatal.

Type of delivery? Vaginal Cesarean

Any complications during delivery?

Are you currently breastfeeding? YesNo

Medical Conditions

Do you have any chronic conditions (e.g., asthma, diabetes)?

Have you experienced pelvic floor issues (e.g., pain, incontinence)?

Are there any mental health concerns (e.g., anxiety, postpartum depression)?

Physical Activity

Were you physically active before pregnancy? YesNo

Are there any movements or positions you find uncomfortable or painful?

Goals for Yoga Therapy

What are your primary goals for participating in this class? Stress management Improving flexibility or strength Pain relief (e.g., back, hips, shoulders) Pelvic floor strengthening Emotional well-beingOther (please specify below)

Other

How do you hope yoga therapy will support you during pregnancy or postnatal recovery?

Lifestyle and Support

How much rest do you typically get each night? ______ hours

Do you feel supported by family, friends, or a community? YesNo

Are there specific areas where you feel unsupported?

Anything else I should know about you?