Prenatal Nurture Yoga - Yoga with Lucie Potter

Prenatal Health Questionnaire

Welcome to Prenatal Nurture Yoga. Please take a minute to fill out this form so I can best support you in class. Thank you! Lucie x

Name*
First Last
Email*
Phone*
Please answer as many questions as applicable. Anything you are unsure about, don't worry, message me on 07727 015703 x
Due Date*
MM slash DD slash YYYY
Hospital you are assigned to / Homebirth*
Emergency Contact Details ( Name & mobile number)*
Please share any relevant / important information relating to previous pregnancies, such as illness or negative outcomes. Be assured this will be treated with utmost confidentiality
Prenatal conditions*
Please tick if yes
- Symphysis Pubis Dysfunction
- Sacrum or SI joint pain
- Carpal Tunnel Syndrome
- Gestational Diabetes
- Low back pain
- Varicose Veins
- Bleeding during or after exercise
- Pain in upper and mid back
If Yes to anything above, add details or share any other symptoms:
Have you done yoga before? If so, how much?*
Complete beginners welcome!
Is there anything else I need to know before you exercise?
Sign here*
Please note if your health changes or you feel unwell in class, do please let me know. You take full responsibility for your own health and safety during class. If you have any reason to believe you may be at risk, check with your doctor or midwife before taking part in class. By typing your name and date below, you agree with these terms and conditions, thank you
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Prenatal Nurture Yoga Class Booking

Prenatal Nurture Class Tuesday 6.15 - 7.15pm

Prenatal Health Questionnaire