Prenatal Yoga Assessment Form

Personal Information

Name

Age

Contact Number

City

Occupation

Emergency Contact

Pregnancy Information

How many weeks pregnant are you?

What is your expected due date?

Day

Month

Year

Is this your first pregnancy? If not, please share details of your previous pregnancies.

Do you have any pregnancy-related conditions (e.g., high blood pressure, gestational diabetes)?

Have you experienced any medical complications during this pregnancy?

Medical History

Do you have any chronic health conditions (e.g., asthma, diabetes, hypertension, etc.)?

Have you had any previous injuries or surgeries?

Are you currently taking any medications or supplements?

Lifestyle and Activity

What are your diet preferences (e.g., vegetarian, non-vegetarian, vegan, etc.)?

How would you describe your current activity level and exercise routine?

On a scale of 1 to 10, how would you rate your stress levels?

How would you describe your sleep quality and average duration?

Goals for Fertility Yoga

What are your main goals for practicing prenatal yoga? (e.g., relieving physical discomfort, enhancing mental relaxation, preparing for labor, improving flexibility, etc.)

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Prenatal Yoga Assessment Form

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