Postnatal Yoga Registration Form

Postnatal Healing Registration Form

Health Form for Postnatal Yoga Healing Workshop

About You
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Phone*
Email*
About You & Your Health
Your Date of Birth*
DD slash MM slash YYYY
Do you have any of the following conditions?
- Asthma
- Allergies (please state details below)
- Epilepsy
- Heart Condition
- Learning Disability
- Physical Disablity
- Other
Do you have other health conditions or general health information that I should know about?
Include problems that you may have experienced prior to pregnancy e.g. Bad back, migraines, carpal tunnel, tendonitis etc.
Are you currently on any medication?*
If ‘Yes’ please state for what condition(s):
Please state if you have had any experience(s) of miscarriage or other pregnancy related events:
About Your Most Recent Pregnancy & Birth
Every pregnancy and birth is different. Providing as much information as you can for each of your pregnancies provides an understanding of your experiences, the effect it had on your body and helps focus attention to areas that need extra attention in class.
Date of the Birth*
DD slash MM slash YYYY
How many children were born?*
- Single
- Twins
- Multiple
Gender of Child/ren*
Name(s) of Child/ren
Did you conceive through IVF?*
Did you suffer with pre-eclampsia?*
Where was your baby born?
If hospital, which? If other, where?
At how many weeks was your baby born?*
Did you have a sweep prior to labour?*
Was your labour:*
If self-starting, was your labour later induced/speeded up?
If induced/speeded up, did you have:
- Oxytocin drip
- Vaginal pessary
- Other
Drugs administered during labour:
- Gas & Air
- Pethidine
- Diamorphone
- Anti-sickness
Other pain relief used:
- Epidural
- Spinal Block
Did your baby present in any of these positions?
- Transverse
- Breech
- Back-to-Back
Nature of delivery:*
- Vaginal
- C-section (following labour)
- Planned C-section
Is the scar healing well?
Intervention during delivery:
- Unassisted
- Forceps
- Ventouse
Did you have an episiotomy?
Did you tear?
To what degree did you tear?
Did you have stitches?
Has the area now healed?
Did you suffer?
- Postpartum Haemorrhage
- Retained Placenta
- Heavy Blood Loss
- Blood Transfusion
Did you experience any medical problems during this pregnancy? If ‘yes’ please explain below:
Did you suffer any other complications during the pregnancy, labour or birth? If ‘yes’ please explain below:
Do you feel that you have suffered with postnatal depression since the birth of your baby?
Have you experienced any of the following since the birth of your baby:
- Anaemia/Dizziness
- Anxiety
- Exhaustion
- Insomnia
- High blood pressure
- Low blood pressure
- Haemorrhoids (Piles)
- Stress Incontinence
- Back Pain
- Joint pain
- Sacroiliac pain
- Stiff Neck/Shoulders
- Parted Tummy Muscles
- Damaged Stomach or Rib Muscles
- Damaged Pelvic Floor Muscles
- PGP (Pelvic Girdle Pain)
- Mastitis
- Prolapse
- Sciatica
If you ticked any of the boxes above, please use this space to expand on the symptoms:
Have you had your 8 week GP check up?
Are you having treatment for any other postnatal issues?
How do you rate the level of care you received throughout your pregnancy?*
- Excellent
- Good
- Poor
- Terrible
Please expand:
How do you rate the level of care you received during the birth?*
- Excellent
- Good
- Poor
- Terrible
Please expand:
How do you rate the level of care you received after the birth / since then?*
- Excellent
- Good
- Poor
- Terrible
Please expand:
Have you experienced other births?
About Your Other Birth, #2
Please share details of your previous birth here.
Date of the Birth*
DD slash MM slash YYYY
Gender of Child/ren*
Name(s) of Child/ren
Did you conceive through IVF?*
Did you suffer with pre-eclampsia?*
If you had an induced/ speeded up labour, did you have:
Did you have either of these pain relief procedures?
- Epidural
- Spinal Block
Did your baby present in any of these positions?
- Transverse
- Breech
- Back-to-Back
Nature of delivery:*
- Vaginal
- C-section (following labour)
- C-section (planned)
Intervention during delivery:
- Unassisted
- Forceps
- Ventouse
Did you have an episiotomy?
Did you tear?
To what degree did you tear?
Did you have stitches?
Did you suffer?
- Postpartum Haemorrhage
- Retained Placenta
- Heavy Blood Loss/ Transfusion
Did you experience any medical problems during this pregnancy or any other complications during this pregnancy/labour/birth? If ‘yes’ please expand below:
Do you feel that you have suffered with postnatal depression since the birth of your baby?
Have you experienced other births?
About Your Other Birth, #3
Please share details of previous birth here.
Date of the Birth*
DD slash MM slash YYYY
Gender of Child/ren*
Name(s) of Child/ren
Did you conceive through IVF?*
Did you suffer with pre-eclampsia?*
If you had an induced/ speeded up labour, did you have:
Did you have either of these pain relief procedures?
- Epidural
- Spinal Block
Did your baby present in any of these positions?
- Transverse
- Breech
- Back-to-Back
Nature of delivery:*
- Vaginal
- C-section (following labour)
- C-section (planned)
Intervention during delivery:
- Unassisted
- Forceps
- Ventouse
Did you have an episiotomy?
Did you tear?
To what degree did you tear?
Did you have stitches?
Did you suffer?
- Postpartum Haemorrhage
- Retained Placenta
- Heavy Blood Loss/ Transfusion
Did you experience any medical problems during this pregnancy or any other complications during this pregnancy/labour/birth? If ‘yes’ please expand below:
Do you feel that you have suffered with postnatal depression since the birth of your baby?
Have you experienced other births?
About Your Other Birth, #4
Please share details of previous birth here.
Date of the Birth*
DD slash MM slash YYYY
Gender of Child/ren*
Name(s) of Child/ren
Did you conceive through IVF?*
Did you suffer with pre-eclampsia?*
If you had an induced/ speeded up labour, did you have:
Did you have either of these pain relief procedures?
- Epidural
- Spinal Block
Did your baby present in any of these positions?
- Transverse
- Breech
- Back-to-Back
Nature of delivery:*
- Vaginal
- C-section (following labour)
- C-section (planned)
Intervention during delivery:
- Unassisted
- Forceps
- Ventouse
Did you have an episiotomy?
Did you tear?
To what degree did you tear?
Did you have stitches?
Did you suffer?
- Postpartum Haemorrhage
- Retained Placenta
- Heavy Blood Loss/ Transfusion
Did you experience any medical problems during this pregnancy or any other complications during this pregnancy/labour/birth? If ‘yes’ please expand below:
Do you feel that you have suffered with postnatal depression since the birth of your baby?
Disclaimer
1. I understand that the Samye Centre will take all reasonable care to ensure that the classes are safe. However, I agree that I will be engaging in physical activity and, as with all forms of exercise, there is the small possibility of injury occurring.
2. I assume these risks and take full responsibility for any possible injury sustained in class.
3. I have been advised to contact my doctor and/or consultant, before participating in the Postnatal Yoga Classes, if I have any medical conditions that could affect my participation. I will inform my yoga teacher should there be any change in my medical condition(s).
4. I understand that it may be necessary for the yoga teacher to appropriately reposition me, to safeguard me from injury, and I consent to this.
Signed:*
Please type your initials to indicate your acknowledgement of the disclaimer and to confirm the submission of information submitted. All data is private and will NEVER be shared without your consent.
Women's Yoga Support Group on Facebook
What is the Women's Yoga Support Group (Samye Centre)? The Women's Yoga Support Group (Samye Centre) is a secret Facebook group run by the Samye Centre to support women from birth to the years way beyond. We post articles, videos and audio teachings of practices to help with residual postnatal issues e.g. parted tummy muscles, mild stress incontinence, and ongoing women's health issues e.g. menstrual health, hormones, the perimenopause & menopause and mental health. We sometimes host online Q&A sessions with experts). There is also an audio recording of the relaxation we do in class, which you can download to use at home. This resource is offered for FREE and is useful for staying in touch, alongside the classes. When you sign up for any Samye Centre yoga class or workshop, you will be asked if you want to join this group. The group is set as Secret; this means that other people who don't belong to the group can see the group exists, but they cannot any information on who is a member of the group. Once joined, you can leave at any time.
Would you like an invitation via email to join the Women's Yoga Support Group?*
- Yes
- No
Contact Preferences
The Samye Centre may wish to send you a reminder text at the start of the course.
If you have selected 'Yes', please ensure you have provided your mobile number at the top of this form.
How do you wish to be contacted if a class has to be cancelled or changed at short notice?*
Please ensure you've included your correct contact details in the Contact Details section above!
- Please notify me by text message.
- Please call me on my contact number.
- Please email me.
Occassionally The Samye Centre would like to email you about other yoga classes available. Please tick if you want information on:
- Women's Yoga Workshops (3 hours)
- Women's Weekly Yoga Circle (Friday Nights)
- Women's Yoga & Youth Hostelling Weekends at YHA Boggle Hole (3 per year)
- Mother & Baby Yoga
- Parent & Toddler Yoga
- Children’s Yoga
- Yoga for Children with Special Needs
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postnatal Yoga Registration Form

Postnatal Healing Registration Form

About You

About You & Your Health

About Your Most Recent Pregnancy & Birth

About Your Other Birth, #2

About Your Other Birth, #3

About Your Other Birth, #4

Disclaimer

Women's Yoga Support Group on Facebook

Contact Preferences