Yoga4lifestyle

STUDENT HEALTH QUESTIONNAIRE

Pregnancy Yoga Health

Questionnaire

Please complete the form to the best of your knowledge and be assured that it will be
treated in the strictest confidence. The questionnaire is just designed to make sure that you
and baby can practice safely. If there is anything you are unsure about or would like to chat
through please get in touch.
Before you fill out this questionnaire and send the form back to Yoga 4 life style, we advise
you read the privacy policy so you understand and accept what happens to your data. By
you forwarding the questionnaire on to us we will assume that you accept the privacy policy
as stated.

Name*

First name Last name

Email address *

Address

Phone number

Age

Occupation

Preferred Contact
Please indicate your preferred method of contact in
o Phone
o E-mail

Which classes will you be joining?

Please tick the appropriate box below:

Face to face classes @ The Nest

Live Virtual Clases

A mix of both

Estimated due date*

Number of weeks pregnant*

Pregnant with twins

Low/high risk pregnancy

If high risk please state why?
Yoga4lifestyle
STUDENT HEALTH QUESTIONNAIRE

PregnancyHealth Check
During this pregnancy what are you currently experiencing? (please tick those that
are effecting you right now)

1 Morning sickness
2 Constipation
3 Nosebleeds
4 Lower back pain
5 High blood pressure
6 Varicose veins
7 Depression
8 Bleeding
9 Stiff neck and shoulders
10 Public pain/girdle pain
11 Headache
12 Sciatica
13 Oedema (swollen joints)
14 Pre-eclampsia
15 Anxiety
16 Dizziness
17 Breathlessness
18 Diabetes
19 Aching joints
20 Placenta previa (covering the cervix, Marinal or
 21 Carpel tunnel (wrist pain)

22 Water retention

23 Anaemia

24 Asthma

25 Sleep disturbances

26 Low blood pressure

27 Piles

28 Cramps

29 No symtoms

Any others symptoms you are experiencing

Pregnancy Yoga Class

Breathing excercies

Strengthening and toning muscles

Relieving specific ailments

Quiet time to bond with baby

Making friend with other Mums

 Relaxation

Supporting good posture through pregnancy

Preparing your body for birth

Other reason ………………………

Is there anything that concerns you or that you would be interest in?

Is there anything you would like me to know about?

Declaration
by ticking this box, I am declaring that I have disclosed to my Yoga teacher all information
regarding my health relevant to the practice of Yoga during my pregnancy. I take full
responsibility for all applications of Yoga I practice in the class and outside the class during
my pregnancy. I fully understand that the recommendations, ideas or techniques expressed
and described in the pregnancy Yoga classes cannot be regarded as a substitute for the
advice of a qualified medical practitioner. Any uses to which the recommendations, ideas
and techniques are put are at my sole discretion and risk.

Tick as signed declaration

SUBMITSUB