Bradley-test

Comfort Techniques Refresher Class Registration

All information is strictly confidential. If you are uncomfortable answering any questions, please leave them blank.

PERSONAL INFORMATION

Expectant Mother’s Name:*

Mom’s Email:

Dr/Midwife:

Cell Number:

Home Number:

Coach’s name:

Coach’s Name:*

Planned birth place

Estimated Due Date:


Class Payment Information

$125.00 Non-Refundable Deposit required to reserve your spot in class. ($130 debit/credit)
Cash or Check payable to Yoga Janda Inc. To pay by credit card use link at bottom of the page.

***SELECT PAYMENT***

Total Cost of Class + Materials = $365.00 (cash/check) $375.00 (debit credit)
**After the 1st class there will be no refunds.


1. Babies in Bloom Client (Not 1st baby/circle one) Y / N

2. In what areas do you feel you need the most information?

3. What are your/coaches fears about the upcoming labor/ birth?

4. Are you experiencing any of the common pregnancy discomforts (ie: leg cramps, headaches, heartburn, backache, constipation, insomnia, itching?)

5. Are you being treated for any more serious health conditions?(ie: high blood pressure, anemia, diabetes, epilepsy, asthma, etc.)

6. What is your exercise routine?

7. How do you rate your eating habits? (quantity/quality)

8. Do you have a job?

What is your occupation, and your coach’s occupation?

9. Tell me about your previous birth experience.

10. Do you have specific goals for the upcoming labor/birth/post-partum?


Mother

Date

Coach

Date