Level of Activity (choose one):
Any problems, discomforts or pains?
Do you have a history of the same problems?
What makes it better?
What makes it worse?
What self-help measures have you tried?
How did you hear about Yogamoms?
Health Care Provider
Word of Mouth
Number of Pregnancies:
Number of Deliveries:
Name of Doctor or Midwife:
Baby's Birthday and Name (postnatal only):