Core Awakening Intake Form (Alaro)

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Email *

Full Name *

WhatsApp Phone Number *

Please clarify your current life stage (are you pregnant, postpartum, perimenopausal, postmenopausal, etc)? If you are a mother, please let me know how old is your last born child? *

What is your main interest for joining this series?

Do you experience any of the following?

leaking urine when laugh, cough, sneeze or exert yourself

experience urgency to urinate, a feeling that you cannot make it to the toilet on time

leaking gas and not able to control

experience urgency to defecate, a feeling that you cannot make it to the toilet on time

experience a bulging or bearing down sensation in the vagina or perineum

Other:

Do you have any known Diastasis Recti (separation of your abdominal muscles)? *

Yes

Maybe

Other:

Have you visited a Women's Health Physiotherapist since your postpartum journey began? *

Yes

Other:

Is there any physical condition, injury, limitation that you are experiencing in your body currently? *

Do you currently have a menstrual cycle? *

Yes

Other:

I understand that it is important to attend all classes in this series. The full series costs 60 € to be paid in full on the first day of my attendance. In the event I cannot join a class, I will have access to a recorded version of a class that is similar. Cancellation to join the series is only possible by 29 May, after which payment in full is kindly required. *

Awesome, I understand

I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. Asana (yoga postures) means posture easily held. If at any time during the online classes, I feel discomfort or strain, I will gently come out of the posture. I may rest at any time during the classes. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be eliminated. If I experience any pain or discomfort, I will listen to my body, stop if I need to and inform Amber of my experience if appropriate. *

I understand

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 should consult a qualified care provider prior to beginning any activity program, including yoga. I recognise that it is my responsibility to notify my teacher of any pregnancy, of any serious illness or injury before I participate in the yoga classes. I affirm that I alone am responsible to decide whether to practice yoga. I herby agree to irrevocably release and waive any claims that I have now or may have against (Embodied Living Pte Ltd, Amber Sawyer, UEN 202030481N). *

I understand

Please write your full name once more as an indication of your digital signature for this form. Thank you! *

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