Baby massage and/or baby yoga booking and health consultation
Thank you for choosing kin2Skin baby massage and yoga. I look forward to meeting you and your baby and share the many benefits of these practices. Before your experience starts, I would like to ask you some questions to be able to accommodate to your needs the best way possible. Please take the next few minutes to fill out this questionnaire. The information will remain confidential and will not be shared with other parties. If you have twins or more babies, please fill out one questionnaire per child as they might have different needs.
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Main parent or caregiver's name: *
Other parent or caregiver's name:
Whoever else will be attending the classes with you (if applicable).
Baby's name *
For twins or more babies, you will need to complete one questionnaires per child as your babies might have different needs.
Baby's date of birth: *
MM
/
DD
/
YYYY
Family's address with postcode
If classes are not going to be in your home, you don't have to share this info
Mobile: *
Email *
What experience would you like to book? *
choose all that apply
Required
Please mention the name of the person who will be hosting in the case of experiences in your home or a friend's home (if applicable)
For classes in the home, if the dates and times have been agreed, please indicate them below (e.g. 5, 12, 19 and 26 Feb 2018, 10.30am). Leave blank if you are unsure
Do you or the person accompanying you have any access requirements? *
Let us know if you/any person accompanying you need a ramp to access facilities, or any other movement or access limitation.
If yes, please give details:
Do you or the person joining you have any back problems or any other difficulty sitting on the floor? *
If yes, please give details:
Do you or the person accompanying you have any health condition we need to be aware of? *
If yes, please give details:
Please answer the following health consultation about your baby: *
Yes
No
Does your baby suffer from any chronic disease?
Does your baby have any skin infections or broken areas?
Will your baby have any immunisation prior to starting baby massage or yoga workshop or during the course? Note: it is recommended to wait 48-72 hrs after a baby has had a jab to resume baby massage or yoga, so try to schedule jab appointments away from the classes, if this is not possible, you can practice with a demo doll
Does your baby have any problems with his/her hips? 
Does your baby have any problems with his/her heart? 
Does your baby have any problems with his/her tummy? 
Does your baby have any known allergies? 
Has your baby had any recent surgery? 
Does your baby suffer from convulsions or any neurological problem(s)? 
Does your baby suffer with wind pains or colic? 
Does your baby suffer from asthma or any other respiratory problem(s)? 
Is your baby currently taking any medication? 
Does your baby have any health care needs or a disability? 
Was your baby born premature? 
If you answered YES to any of the questions above, please give details:
Additional comments:
Is there any relevant family medical history or anything else you would like to notify the instructor before starting the baby massage or yoga experience?
Would you like to sign-up to our newsletter? *
Our newsletter is valued packed, with relevant information for families with babies, interesting facts and resources (you can opt out at any point and we will not share your details).
How did you hear about kin2Skin baby massage and yoga? *
I declare that the information I have given about myself, any person accompanying me and my baby is true and correct as far as I am aware. I have responsibility for the health and wellbeing of my child during and after the classes and will carry out any massage and yoga within the guidelines presented by the instructor and observe any contraindications to massage and yoga as advised by the instructor. I consent to receiving baby massage and/or baby yoga instruction. *
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