Bradley-test

Comfort Techniques Refresher Class Only Registration

All information is strictly confidential. If you are uncomfortable answering any questions, please leave them blank. THIS REGISTRATION IS FOR REFRESHER CLASS ONLY! To register for the Bradley Method go to: https://yogajanda.com/registration/

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

$68.00 required to reserve your spot in the REFRESHER class.
Cash or Check payable to Yoga Janda Inc. To pay by credit card use link at bottom of the page.

***SELECT PAYMENT***

1. Babies in Bloom Client Y / N

2. This is NOT my 1st baby Y / N (if it is your 1st baby go to: https://yogajanda.com/registration/

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

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

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

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

7. What is your exercise routine?

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

9. Do you have a job?

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

9. Tell me about your previous birth experience.