Client Initial Consultation Form Cont. Prenatal / Postnatal

Client Initial Consultation Form Cont. Prenatal / Postnatal

For exclusive use of She-Wolf Wellness
Section 1:
Date

MonthDayYear
Date
Did you have a yoga practice before you were pregnant?

NoHere and thereA few times a weekNearly every day!No but I participate in other fitness activities
Have you previously had children?

No, first time!Yes!
If so, how many?
If you've previously had children, have you taken a postnatal class before?

YesNoI went back to my regular yoga practice / fitness routine
If Postnatal, please skip ahead to section 3.
Section 2: Prenatal
How many weeks are you along?
Have you taken a prenatal yoga class before?

YesNo
What symptoms are you currently experiencing?

Extreme tiredness / FatigueTender / Swollen breastsUpset stomach / SicknessCravings / Distaste for certain foodsMood SwingsConstipationNeed to urinate more oftenHeadacheHeartburnLight-headed when standing for long periods of timeBody aches in lower backAches in abdomenAches in groin / PelvisNumbing / Tingling Hands ( Carpel Tunnel )Itching of abdomen, palms, soles of feetDisturbed SleepHot flashes / SweatsShortness of BreathSwelling of ankles, fingers, and facePre-lactation ( Colostrum)Have been told the baby may be breechedPelvic Girdle Pain (PGP) or Symphysis Pubis Dysfunction (SPD)High Blood PressueLow Blood PressurePendulas Abdomen ( Ab Separation )Other
Please skip ahead to section 4.
Section 3: Postnatal
How many weeks since you gave birth?
Did you attend prenatal yoga classes during your pregnancy

YesNoNot prenatal but I continued with a yoga practice during my pregnancy, restorative or otherwise.
Did you experience any of the following during this childbirth?

Damage to the paraneimC-section ( Unplanned )C-Section ( Planned )Use of forecepsPremature birthSeparation of the abdominal muscles ( Diastaisis Recti )Other
Section 4:
Are there any other health issues / concerns you would like to share or expand upon?
Is there anything further you would like to share about your pregnancy or previous births?
As far as I am aware, I have disclosed to She-Wolf Wellness all information regarding my health relevant to the services provided.

I take full responsiility for my body and my participation in the agreed upon activities.

I fully understand that the recommendations, ideas or techniques expressed and described for these sessions cannot be regarded as substitute for the advice of a qualified medical practitioner.

Any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk.
Electronic Signature Required (Via Touchscreen or Mouse)*

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