Pregnancy Yoga Health Questionnaire and Booking Form

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Your information will only be used for planning appropriate yoga classes that meet your needs. Your information will be kept secure and not shared with anyone else. We will hold your information for 7 years. You can opt out any time.

Email *

Class Information

Classes run each week, Mondays (apart from bank holidays) at 7pm at Clear Space Studios, Hereford.

You might like to wear something comfortable. If you are able to please bring a cushion, pillow and a blanket. At Clear Space we have yoga mats. The pillows etc are really helpful to be comfortable and to learn ways of being comfortable at home too.

You’re welcome to bring a drink in a closed bottle/cup, even a small snack for just after class, whatever you need to be comfortable.

To book please contact me, Angela on 07758114844 to let me know you are booking, complete this form and bring or send payment.

For payment by BACs 089300 04285203, I also accept cash. It’s £11 drop in, £50 for a block of 5 to use in 8 weeks or £95 for a block of 10 to use in 13 weeks.

Parking should be available outside on King St and Bridge St. As it’s after 6pm it’s free. There’s a map on the Clear Space website in case you need it Yoga & Movement Studio | Hereford | Clear Space Studios

You can ask me any questions or let me know of any changes at any time. Keep my number handy in case you need anything just before the class.

Would you like to join my email newsletter?

Yes

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Your name

Your date of birth

YYYY

Your due date

YYYY

Emergency contact name and number

Planned place of birth

Midwifery practice

What Yoga have you practiced before?

What do you hope to gain from these classes?

Where did you hear about this class?

During this pregnancy, have you experienced any of the following or any other health issues which you feel may have some bearing on your Yoga practice?

Morning sickness

Constipation

Nosebleeds

Lower back pain

Varicose veins

Depression

Bleeding

Headaches

Heart burn

Anaemia

Anxiety

Sciatcia

Oedema

Pre-Eclampsia

Dizziness

Breathlessness

Diabetes

Pelvic pain

Sleep distubance

Other:

Prior to this pregnancy, have you suffered any injury or undergone any surgery (e.g. caesarean birth, knee surgery) that may have some bearing on your Yoga practice? If so please give details

Have you had any previous pregnancies?

Yes

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Have you had any previous miscarriages?

Yes

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Have you had any previous births?

Yes

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Are you taking any form of medication that may have some bearing on your Yoga practice?

Is there anything else you would like to tell me?

I take full responsibility for my health and of that of my baby at these yoga sessions. I will inform my yoga teacher of any medical changes. Please type your name to sign and agree. *

Thank you for completing this questionnaire. I hope you enjoy enjoy the classes. Don't hesitate to contact me if you have any questions. Angela

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