Nourishing the Pelvic Landscape: Intake Form

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Email *

Full Name *

WhatsApp Phone Number (if you are doing the in-person event, please provide. If joining an ONLINE event, no need to share number)

What are some of the main reasons you have for attending this workshop?

To know a little bit about the women attending, please check all that apply, if you feel comfortable to do so:

I am in puberty

I am pregnant

I have given birth before (C-section or vaginal delivery)

I am peri-menopausal (or think I might be)

I am menopausal

If you have given birth previously, how far postpartum are you from your most recent birth?

Though these are sensitive questions, your answers will help Amber to cover specific topics that will be relevant to the group attending, as well as to cultivate a sensitivity in how we approach some of the exercises. Please note this information remains entirely confidential. 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

pain on intercourse or inserting anything into the vagina (tampon, mooncup, finger, etc)

hip pain or sacral pain

chronic urinary tract infections

have had a miscarriage

have experienced sexual trauma

have any difficulty connecting to your pelvic terrain (physically, emotionally or mentally)

Other:

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

Yes

Maybe

Other:

Clear selection

Have you ever visited a Women's Pelvic Health Physiotherapist? *

Yes

Other:

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

Which workshop are you registering for? *

I am waiting for an in-person offering or different dates

REPLAY: 2 Feb 2023, 3h workshop, available until 16 Feb

Other:

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 class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body and inform my teacher immediately. *

I agree

I disagree

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 physician prior to beginning any activity program, including yoga. I recognise that it is my responsibility to notify my teacher of my pregnancy, of any serious illness or injury before every yoga class. 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 hear free may have against (Embodied Living Pte Ltd, Amber Sawyer, UEN 202030481N). *

I agree

I disagree

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

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