Client Initial Consultation Form Cont. Prenatal / Postnatal

Client Initial Consultation Form Cont. Prenatal / Postnatal

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

Month Day Year
Date
Did you have a yoga practice before you were pregnant?

No Here and there A few times a week Nearly 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?

Yes No I 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?

Yes No
What symptoms are you currently experiencing?

Extreme tiredness / Fatigue Tender / Swollen breasts Upset stomach / Sickness Cravings / Distaste for certain foods Mood Swings Constipation Need to urinate more often Headache Heartburn Light-headed when standing for long periods of time Body aches in lower back Aches in abdomen Aches in groin / Pelvis Numbing / Tingling Hands ( Carpel Tunnel ) Itching of abdomen, palms, soles of feet Disturbed Sleep Hot flashes / Sweats Shortness of Breath Swelling of ankles, fingers, and face Pre-lactation ( Colostrum) Have been told the baby may be breeched Pelvic Girdle Pain (PGP) or Symphysis Pubis Dysfunction (SPD) High Blood Pressue Low Blood Pressure Pendulas Abdomen ( Ab Separation )
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

Yes No Not 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 paraneim C-section ( Unplanned ) C-Section ( Planned ) Use of foreceps Premature birth Separation of the abdominal muscles ( Diastaisis Recti )
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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