General, Perinatal & Therapeutic Yoga

Private Classes & Yoga Therapy

* required  * required Your address:  * required  * required Emergency contact name and number: I'm male I'm female  * required  * required Why are you interested in private yoga classes or yoga therapy? Have/are you seeing any other medical or alternative practitioners? Have you had to take time off work or not been able to do what you normally do recently? Have you any previous experience of yoga?  * required  * required Please select - energy levels Energy levels - good Energy levels - moderate Energy levels - poor Energy levels - erratic Please select - appetite Appetite - good Appetite - moderate Appetite - poor Appetite - erratic Please select - sleep onset Sleep onset - fast Sleep onset - takes time Sleep onset - erratic Please select - sleep quality Sleep quality - good Sleep quality - moderate Sleep quality - poor Sleep quality - erratic Please select - bowel habits Bowel habits - regular Bowel habits - erratic Bowel habits - problematic Please describe your typical diet, noting if vegetarian, diabetic, coeliac, etc and whether your mealtimes are regular or erratic: Do you drink and if so, approximately how many units and how often? Do you smoke and if so, how many a day? Do you exercise and if so what type and how often? What are your interests? What is the medical history of your family on both your mother and father's side? Please give details of your medical history including any surgery, accidents and illnesses: Please give details of any medication you're currently taking: Women only: I am pregnant: I am not pregnant If pregnant, please state due date and other pertinent information such as carrying twins, etc: If pregnant, use Ctrl key to select all that apply: Anaemia Anxiety Back pain Bleeding Breathlessness Constipation Depression Diabetes Dizziness Headaches Heartburn High Blood Pressure Morning Sickness Nosebleeds Pelvic Pain Pre-eclampsia Sciatica Sleep disturbances Varicose Veins Menstruation - please select Menstruation - not applicable (pregnant) Menstruation - naturally regular Menstruation - naturally erratic Menstruation - absent Menstruation - problematic Menstruation - synthetically controlled  * required Use the Ctrl key to select all that apply: Not applicable (male) Type of births - natural Type of births - assisted Type of births - caesarean Menopause - please select: Pre menopausal Post menopausal Taking HRT And finally: Please select how you found me: I found Liz Brown Yoga via the internet I was recommended by a friend / colleague Please use this space to enter any other comments, including your availability: By pressing 'submit', you confirm that: the above information is correct and complete and that you're willing to provide further information if required.   you're happy for these notes to be used to facilitate your private/yoga therapy sessions and that they may be used anonymously as case studies for my further training.