Birth Preparation Workshop Registration form

Please email Sofya to find out the dates of the next workshops and to book your place before filling in the form and returning it with your £20 deposit

Please note that all information given on this form will be treated as strictly confidential. The information given allows me to plan sessions in order to meet the needs of mothers and their babies and to ensure that the sessions are suitable and appropriate for those wishing to attend.

Name:

Name of birth partner:

Address:

 

Phone: (work and home):

 

Due date & planned place of birth :

 

Occupation:

Date of Birth:

 

Occupation:

 

Midwifery practice:

Have you studied yoga before? Please give details of how long, what style of yoga etc.

 

During this pregnancy, have you experienced any of the following? Please circle those conditions which have affected you.

Morning sickness, Headaches, Dizziness, Constipation, Heartburn, Breathlessness , Nosebleeds, Anaemia, Diabetes, Lower back pain, Sciatica, Aching groins, Varicose veins, Oedema (swollen joints), High blood pressure, Pre-eclampsia, Depression, Anxiety, Sleep disturbances, Bleeding, Pain from fibroids.

Please give details of any of the above which you have circled, or any other health issues

 

Prior to this pregnancy, have you suffered any injury or undergone any surgery (e.g caesarean section, knee surgery) ? If so, please state details.

 
Previous pregnancies?
Previous miscarriages?
Previous births? Please give ages of children.
Do you smoke?

Are you taking any form of medication that I should be aware of

 

Are there any foods or drinks that you are allergic to?

 

Thank you for completing this form.

 Please send it to me with your deposit