What is your date of birth? *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous birth experience (if applicable) *

Vaginal birth

Caesarean birth

Vaginal birth after caesarean (VBAC)

Other

Do any of the following apply to you? *

Anemia

High blood pressure

Low blood pressure

Vaginal bleeding during pregnancy

History of pregnancy loss

Previous premature labour

Carrying twins or multiples

Joint problems

Varicose Veins

Haemorrhoids

Placenta Previa or low lying placenta

History of depression or postnatal depression

Carpal Tunnel

Symphysis pubis dysfunction

Sacroiliac joint dysfunction

Pelvic pain

Back pain

Sciatic pain

Leg cramps

Fluid retention

Heartburn

Nausea

Other

What would you like to get out of yoga? *

Relaxation

Stress management

Flexibility

Strength

Relief from aches & pains

Community/Connection

Other

I have answered the above questions, fully and truthfully to the best of my knowledge. *

Please print name as signature.

First Name

Last Name