Pregnancy Yoga with CharlottePlease complete this form in advance of your first pregnancy class with me Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact (name & phone) Estiated Due Date * MM DD YYYY Is this your first pregnancy? Yes No Have you had any complications in this or previous pregnancies? Are you under any medical or midwife restrictions for exercise or movement? Yes No If yes, please explain further Have you done Yoga before? Yes No How are you feeling in your body right now? Are there any areas of discomfort or conditions relating to your pregnancy I should be aware of? Are you taking any medications I should be aware of? Please let me know about any previous injuries or surgeries? What are you hoping to get out of Pregnancy Yoga? Relaxation Connection with my baby Gentle movement Strength and stamina for birth Stress relief Other Class participation agreement I confirm that I have consulted my healthcare provider and am fit to attend a Pregnancy Yoga class I agree to let my teacher know if anything changes after completing this form Thank you!
