Registration

* indicates required field

Personal Information

Expectant Mother’s Name:

Phone Number(s)*

Cell:

Mom’s-to-be Email:*

Planned Birth Place:

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.

Payment with Registration

Total Cost of Class + Materials = $365.00 (cash/check) $375.00 (debit credit)

**After the 1st class there will be no refunds.

QUESTIONS AND INFORMATION

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

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

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

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

4. (MOM)Do you _ to read (reading)?

love
like
tolerate
hate

4. (COACH)Do you _ to read (reading)?

love
like
tolerate
hate

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. Do you smoke cigarettes?

yes
no

8. Do you spend time with Someone who smokes?

yes
no

9. Do you take over-the-counter drugs or prescription drugs?

yes
no

10. Do you drink alcohol?

yes
no

11. Do you have a cat?

yes
no

12. Do you wear your seat belt?

yes
no

13. Do you lie on your back?

yes
no

14. What is your exercise routine?

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

16. What are your feelings about weight gain?

17. Do you:

drink caffeine
limit your calories
take vitamins

18. Do you:

have a job?
plan to return to work after the baby is born?

What is your occupation?

What is your coach’s occupation?

19. What are your feelings about breastfeeding?

20. Have you had breast surgery of any kind? If so, please explain.

I understand that the information given in each class is of great importance to decisions we may be making concerning the health of mother and baby. Attending every class is ideal. If one of you can’t attend, I encourage one of you to attend on your own or bring a substitute coach.

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