Mama Flow - Registration and Health Questionnaire 
CONFIDENTIAL
Thank you for completing this questionnaire. It helps ensure safe classes/workshops, supports treatment planning and guides any needed referrals. If you’d rather discuss anything in person, you can leave non-required sections blank.  Any information will not be passed to third parties.
Sessions can be book at  Mama Flow Bookings

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Email *
Your name *
How do you like to be addressed and any pronoun preferences? 
Which session(s) are you interested in?
How did you find out about us?
Mobile number *
Home address
Emergency name and number *
GP Practice / Midwife Practice / Consultants (if applicable)
Medical clearance to attend sessions *
Required
Your occupation
Regular sports, hobbies and leisure activities
CURRENT PREGNANCY QUESTION (if applicable) - When is your Estimated Due Date?
CURRENT PREGNANCY QUESTION - please give details of any extra tests, medical care or consultant care you are having.
CURRENT PREGNANCY QUESTIONS - Have you experienced any of the following? 
PREGNANCY HISTORY - please list the date(s) of any previous births.
PREGNANCY HISTORY  (if applicable)  - have you had any of the following? 
PREGNANCY HISTORY (if applicable) - please give as much detail of your birth story(s) as you are comfortable sharing
General health - do you have any other ongoing medical or health conditions? 
Do you regularly take any medications or supplements? 
Have you had any injuries, treatments medical investigations or surgery during the last 12 months? 
Are you awaiting treatments, investigations or surgery? 
TREAMENT QUESTION
Your comfort and preferences matter, so please share anything that will help make this treatment right for you.

What are your goals for treatment?
TREAMENT QUESTION
Do you have any allergies or preferences to oils, scents or other skin products? 
TREAMENT QUESTION 
What pressure do you prefer? 
Are there any areas you would especially like worked on / avoided?
Are there any techniques you particularly enjoy or really dislike?
TREAMENT QUESTION 
Would you prefer quiet, light conversation, guided relaxations or breath-work?
TREATMENT QUESTION
Exact location of the pain / discomfort?
Possible causes?
Gradual or sudden onset?
Have you had this before?

TREATMENT QUESTION
Is the sensation shooting, stabbing, throbbing, hot, swollen?
Does the sensation refer anywhere else?

TREATMENT QUESTION
How long does the pain / discomfort last?
When does it come on?
How often does it occur?
Does it stop you from doing anything?
How bad is it from 1 (very mild) - 10 (very bad)?
TREATMENT QUESTION
Are you experiencing night pain?
Do you get nights sweats?
Do you have any associated weakness or numbness?

TREATMENT QUESTION
What makes it better?
What make it worse?
Have you had any medical help, or other treatments?
Thank you for your time.  Is there anything else you would like to add or questions you would like to ask?

Cancellation Policy

I understand when I book a class or treatment it is subject to the current refund and cancellation policy as outlined in the booking confirmation email.

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Declaration

I understand that Mama Flow will not be liable for any loss, damage or injury that may occur whilst on the premises, or during an on-line session.

I take full responsibility for all applications of yoga, techniques and massage I may practise during and outside the classes.

I take full responsibility over the health of my child/children/ charges and myself in the yoga and massage sessions.

I will complete a Health Questionnaire before attending my session. Or other Registration form as requested.

If needed I have sought medical approval to attend sessions.

Should there be any medical change I will inform my session practitioner.

I agree to adhere to all current guidelines and legislation regarding infectious diseases, including Covid.

If I have a high temperature, or significant infectious illness I will not attend session, and inform my session practitioner if necessary.

I understand all information provided by me is treated confidentially and not passed on to any third parties. 

 *
Required
Contact permission

For the purposes of handouts, class updates, administration and occasional promotional information, I give permission for you to contact me via email and/or messages.  All information supplied is confidential and will not be passed on to any third parties. I understand I can opt-out at any time.
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