Prenatal Yoga Intake Form

If you are a new yoga client, please take a few moments to fill out the short questionnaire below. This will help me in planning our sessions together!

Name

First Name

Last Name

Phone

(###)

###

####

What is your estimated due date?

Where are you planning to give birth?

Have you taken a yoga class before? If so, what level do you consider yourself to be at?

Do you have any aches, pains or injuries related to pre-pregnancy or your current pregnancy?

Are there any special conditions pregnancy related or otherwise that you would like to disclose?

Props required for our prenatal yoga classes include: a yoga mat, two blocks, a blanket and a bolster (or thick pillow). Do you have any of these?

Are you currently working with a birth doula? If not, would you like information about my services or other referrals?

Would you like any additional resource recommendations? Services I highly recommend include: Childbirth Education, Postpartum Doula Support, Acupuncture, Chiropractic, Lactation Support & Pelvic Floor Therapy.