Mum & Baby Yoga Health Questionnaire

HEALTH QUESTIONNAIRE - Please complete the form below before starting Mum & Baby Yoga:


AboutYou


Full Name

Date of Birth

Email address

Emergency Contact name

Emergency Contact tel. no:

Have you attended yoga before?
YesNo

If yes, how long have you practised yoga and what style of yoga have you practiced?

Are there any medical conditions that I need to be aware of that may affect your ability to do yoga (injury, epilepsy, asthma etc)? Please state below:



Please tick if any of the below apply to you:


Symphysis Pubis Dysfunction (pain in the central pubic area)Sacrum or Sacroiliac joint pain (pain in the very low mid back – top of buttocks)Bleeding during or after exercise or any unexplained bleedingCarpal Tunnel Syndrome (Wrist/finger/hand forearm - pain/numbness or tingling)Knee pain (Side, front or back)Episodes of high/lowblood pressureEpisodes of faintness, or breathlessness,Upper back/neck/shoulder painCoccyx damage or painSeparation of your abdominal musclesIncontinence (urinary or faecal)Prolapse (uterine, bladder, rectum, vaginal)Breast health/breast feeding Issues/MastitisPiles/Haemorrhoids/Varicose Veins/ConstipationWere you given an Epidural during birthing?Nerve damage during birthing (Pudendal)Gestational DiabetesC-Section wound discomfort or slow healing or ongoing numbnessAnaemia or taking Iron medicationJoint pain / muscle painButtock/Piriformis pain/SciaticaEpisiotomy cut, painful perineum or tears


Have you suffered from Diastasis Recti (seperation of the abdominal muscles)?
YesNoDont Know

If yes, how severe was it (centimetres)? *Put N/A if none*

Do you still have a slight seperation? (Your doctor will usually tell you)
YesNoDont Know

About Your Birth


Date of delivery

Type of delivery?

6 week check up date

Has your doctor told you that you may now participate in exercise?
YesNoDidn't say

Are you breastfeeding?
YesNo

If you had a vaginal birth, are you still bleeding (Lochia)?
YesNo

About Your Baby


Will your baby be joining you for Mum & Baby Yoga?
YesNo


How old is your baby?

Does your baby have any medical conditions that I need to be aware of (injury, epilepsy, asthma etc)? Please state below:

Do you understand that you are completely responsible for your baby during the yoga class?
YesNo

Please read the terms and conditions below before clicking submit:


I understand that yoga includes physical movements. As is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated. I am aware that participation in a sport or physical exercise, such as yoga, may result in accident or injury, and hereby assume the risk connected with any participation in this class.


I acknowledge that Lorna Lowe or LoYoga has not and will not render any medical services including medical diagnosis of mine or my babies physical condition. I will let Lorna know if my own or my babies medical needs change.


I specifically agree that Lorna Lowe and LoYoga shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on account of, any kind of personal injury, property damage or loss of any kind resulting from or related to my participation in any exercise or activity within LoYoga, and I agree to hold Lorna Lowe and LoYoga harmless from the above.


Lorna is unable to offer a refund for any missed classes.

Yes By ticking this box you agree to the terms and conditions above.