Pelvic Health Form

Name *

First Name

Last Name

What do you seek to gain from prenatal, postnatal or pelvic health yoga?

Relaxation

Stress Management

Flexibility

Strength

Relief from Back/Neck pain

Birth Preparation

Support for Pelvic Floor

Support for chronic pain

Other (please specify)

Do you have any of the following?

High blood pressure

Low blood pressure

Heart Problems

Asthma

Arthritis

Carpal Tunnel

Neck problems

Back problems

Diagnosed SIJ issues

Diagnosed SPD

Diagnosed Sciatica

Urge incontinence

Stress incontinence

Prolapse

Are you suffering from any of these common complaints?

Fluid retention

Leg cramps

Aching hips

Heartburn

Insomnia

Nausea

Fatigue

Headaches

Sinusitis

Are you breastfeeding?

Yes

No

Are you currently pregnant?

Yes

No

Do you have a history of miscarriage

Yes

No

Is this your first baby?

Yes

No