Mum & Baby Yoga Classes, Baby Reflexology One2Ones Consultation Form

Name

Date Of Birth

Your Age

Address

Phone Number

Mobile Number

Best Time To Call

Name and mobile number to contact in an emergency?

Baby’s name

Weight at birth

Baby’s age at start of class

Doctor’s name

Doctor’s address

Please list briefly any medical problems you had during pregnancy (e.g. high blood pressure, back pain etc.)

Please write a short description of your labour (include pain relief used, medical intervention, C-Section etc).

Are you or your baby presently on any medication (please give details)?

Did your baby require any special care (please give details)?

Has your baby had immunisations at 6-8 weeks

No Yes I have chosen not to immunise my child.

Have you had any Post Natal Check up by a medical profession?

No Yes

Has your baby had any Post Natal Check up by a medical profession?

No Yes

If No do you have any health concerns about yourself or your baby?

Does your baby have any medical condition I should be aware of?

Do you feel you have suffered depression since the birth of your baby?

Have you done Baby Yoga/Pregnancy Yoga before?

No Yes

If Yes then who with?

Have you used Baby Yoga books/videos or classes before?

No Yes

If Yes how many classes have you attended?

How confident do you feel with the Baby Yoga moves you use? Please Circle Confident or Not Confident?

Is there any further information medical about your own health or your baby’s or anything else relevant that you would like to make me aware of?

By completing this form you agree that you have read and understood the following Safety Guidelines. Please ask for a copy of these safety guidelines at your first class, or print screen this page.

I agree to seek medical advice if in doubt about doing Baby Yoga/PostNatal Yoga.
I take full responsibility over the health of my baby and myself in the Baby Yoga/Baby Reflexology and PostNatal Yoga sessions and should there be any medical change I will refer to my own General Medical Practitioner and inform my yoga teacher Melanie Jones.
In class, I will observe the teacher and check that I feel safe, secure and confident before trying each Baby Yoga/PostNatal move.
I realise that when practicing Baby Yoga with my baby that I should never rush or force them, and never do anything that I am not comfortable with.
If my baby is, crying excessively, is distressed and cannot be comforted they maybe unwell so I will stop the Baby Yoga. I will never do Baby Yoga if my baby is limp, pale, has a temperature or any difficulties breathing, and seek appropriate medical help.
I understand that doing Baby Yoga with my baby is not recommended If I am in the first 14 weeks of a pregnancy. Baby Yoga is not recommended within 24 hours of my baby’s immunisations.

May I keep your name and contact details on my database to contact you for any reason? We will not sell or misuse your data in any way under GDPR 2018 guidelines.

No Yes

All YES’s are entered into an annual prize draw and could win a treatment with Melanie.

Please note that this medical information and contact information has to be kept for your baby up to 27 years for insurance purposes.

Mum & Baby Yoga Classes, Baby Reflexology One2Ones Consultation Form

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