* indicates required field

    Personal Information

    Expectant Mother’s Name:*



    Birth Coach/Partner/Husband/Other:*




    Class Date Registering For:*


    Planned Birth Place:

    Estimated Due Date:


    $130.00 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.

    Total Cost of Class + Materials = $395.00 (no cost to Babies in Bloom clients)

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


    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/postpartum?

    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)?

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

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

    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?

    8. Do you spend time with Someone who smokes?

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

    10. Do you drink alcohol?

    11. Do you have a cat?

    12. Do you wear your seat belt?

    13. Do you lie on your back?

    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:

    18. Do you:

    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.

    Payment/Deposit Due with Registration or Paypal -

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