Active Birth Pregnancy Yoga Classes Registration
Name
Any other children
Tiredness
Depression
High Blood Pressure
Low Blood Pressure
Low Placenta
Bleeding
Heartburn
Sleeplessness
Restless Legs
Other Problems/Allergies
Address
Postcode
Mobile
Home Tel
Email
Please contact me via
Your Age
Other Childrens Ages
Profession
Are you planning to go back to work
Due Date
Where do you plan to give birth
Are you happy with this choice
Pubic Pain
Who will be attending the birth
Any Problems with the following. (please click each appropriate one)
Varicose Veins
Back Pain
Nausea
Anxiety
Anaemia
Constipation
Numbness
Breathlessness
Haemorhroids
Leg Cramps
Miscarriages
Terminations
Complications, present or previous
Operations
Past Injuries
Please indicate preference by inserting 1-3 in the boxes. 1-most prefered 3-least prefered or put a cross if you cannot attend any particular class
Tues 12.15-1.45pm
Wed 7.30-9.00pm
What date would you like to start
How did you find out about the class
I agree, for my own safety and well-being, to inform the teacher at the beginning of the class, should any changes in the above information occur, or if any medical, physical, or emotional problems should arise at any time during my Active Birth preparation.
I will be paying my registration fee by..
Obstetric/Gynae History:
Tues 7.30-9.00 pm
Pregnancy Yoga
Birmingham
Special Offer
Free Class
Please
Click Here!
To book your class call
0121 449 9803
or book online