Which class are you interested inPregnancy Yoga Tuesdays 7.00-8.15pmGentle Yoga Mondays 15.30-16.45Couples Birth Preparation WorkshopOne to oneOther
Due date & planned place of birth
Have you chosen to give birth at home?YesNo
Have you done Yoga before?YesNo
If yes, how long have you been practising for?
Have you ever practiced Pilates?YesNo
Before you were pregnant, did you do any sport or type of exercise?YesNo
If yes which
Are you currently doing any sport or type of exercise?
Why have you come to Yoga and what do you hope to gain from it?
Is this your first pregnancy?YesNo
If no, please give age of children
Do you smoke?YesNo
Are you currently taking any form of medication?YesNo
If yes, please give details
During this pregnancy, have you experienced any of the followingMorning sicknessHeadachesDizzinessSleep DisturbancesConstipationHeartburnBreathlessnessAnxietyNosebleedsAnaemiaDiabetesDepressionLower Back PainSciaticaAching GroinsPSDVaricose VeinsOedema (swollen joints)High Blood PressurePre-Eclampsia
Please give details of any of the above you have ticked and/or other health issues you may encounter
Have you suffered any injury or undergone any surgery (i.e. cesarean section, knee surgery, etc) which might affect your Yoga practice? If so, please give details
Do you have any allergies or dietary requirements:YesNo
If yes, what kind
How did you hear about the class?
Would you like to keep in touch with Marylines news of classes, workshops, audio and video material. If yes, we'll add you to our mailing list. Your details won't be shared with anyone else.YesNo
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