Pregnancy Registration & Agreement

Pregnancy Health Questionnaire Form

Name *

First

Last

Email Address *

Contact Number *

Emergency Contact name and number (only required for classes in person)

1. Have you practiced yoga before? *

Yes No Please consult your Doctor If you have any concerns about your health and before participating in any / new type of exercise.

2. How many weeks are you? *

3. When is your Due Date? *

4. Is this your first baby? *

Yes No

5. If you answered No and wish to share information about your previous birth (e.g c-section, early, premature, overdue) please do so in the box below or alternatively type N/A. *

6. Do you have High or Low Blood Pressue? *

Yes - High Blood Pressure Yes - Low Blood Pressure No

7. Do you have any of the following? Fluid Retention / Leg Cramps / Aching Hips / Heart Burn / Nausea / Other (please specify) or alternatively type N/A *

Please provide details you may feel relevant in the box.

8. Do you have any of the following? Asthma / Arthritis / Carpal Tunnel / Heart condition / any concerns with your Neck, Back, Knees, Shoulders or Other (please specify). Alternatively please type N/A in the box below. *

Please provide details you may feel relevant in the box.

9. Declaration: I will consult my Doctor for any concerns about my health before participating in Yoga and inform the teacher of any health concerns/issues that may affect my practice. *

Agree

10. All classes are currently delivered online via Zoom, by submitting this form you agree to take full responsibility for your personal health and wellbeing for the full duration of the session. *

Agree During your practice please listen to your body and feel comfortable in a yoga pose. If at any point a pose feels uncomfortable or painful please do pause and take a rest at any time during the session.

11. Informed Consent / Agreement *

I understand that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I hereby agree to irrevocably release and waive any claims that I now or hereafter, may have against (Deepa Chahal at Yoga Challo).

12. By submitting this form, you give permission to receive emails. This will keep you informed on current services available. This is following General Data Protection Regulations (GDPR) 25th May 2018. *

Agree

Signature: *

Date *