Pregnancy Feedback Form

Name

Age

Gender

1. Purpose of joining Niruddha Yoga & health Studio (NYHS):

Fertility Conceiving Prenatal Postnatal

2. Have you undergone fertility treatment before?

3. Was the Fertility/ Conceiving/ Prenatal/ Postnatal treatment successful with NYHS?

4. How many deliveries you had in past (If any)?

5. How many child/children you have (if any)? Girl__, Boy__

6. Which was the month/ trimester of pregnancy started with NYHS? _

7. Did you complete your pregnancy with NYHS? Yes/ No. If Yes, from__to __

8. Was there any complication/s in your pregnancy when you started with NYHS? __

9. Could you get complication/s solved or decreased by NYHS with your treatment?

10. Were you kept on any medication or dietary supplement/s by your Doctor? If yes, please mention: __

11. Could you get medication/s or dietary supplement/s reduced with the help of NYHS?

12. Have you tried Yoga in your earlier Fertility/ Conceiving/ Prenatal/ Postnatal treatment before?

13. Did you feel safe while practicing yoga?

14. Are you confidant now?

15. Do you feel that yoga is very necessary/ important in Fertility/ Conceiving/ Prenatal/ Postnatal?

16. How strongly you suggest yoga for Fertility/ Conceiving/ Prenatal/ Postnatal ?

17. Do you feel diet is an important part of Fertility/ Conceiving/ Prenatal/ Postnatal?

18. How was your delivery experience after yoga?

How do you rate your experience with NYHS:(1-5)

Signature

Date

Place

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