Pregnancy Screening Form
Is this your first baby?
How many weeks pregnant are you?
Estimated due date?
Their relationship to you?
During this pregnancy, have you experienced the following - please select ALL that apply:
low back pain
high blood pressure
stiff neck and shoulders
pubic pain/pelvic girdle pain
oedema (swollen joints)
low blood pressure
placenta previa (covering of the cervix) marginal or complete
carpel tunnel syndrome (wrist pain)
Why are you attending this class and what do you hope to gain from it?
interest in breathing aspects
strengthening muscles and toning
relieving pregnancy related ailments
time to bond with your baby
making friends with other mums
How did you hear about this class?
Dorchester Yoga Website
Kim Jones Wellbeing Website
Are you interested in the following?
Birth preparation classes
Please check this box to let me know that you agree to me contacting you by email with details of my classes and services and to notify you of any changes to class times or cancellations.
DATA PROTECTION: Please check this box to confirm that you understand that Kim Jones Wellbeing will hold the personal information you provide here securely and will not share this information with any third parties without your prior consent.
Yes, I understand.
Please let me know if you are happy to receive my newsletter and details of events that I am running by email.
Yes, I am happy to receive emails from Kim Jones Wellbeing
No, please do not email me with news and information about events.
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