Prenatal Yoga Class Medical Clearance

Prenatal Yoga Class Medical Clearance — Form Fields

This healthcare template includes 14 fields. Medical clearance form for pregnant women enrolling in prenatal yoga classes. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• OB/GYN Provider Name (text, required)
• Provider Phone (text, required)
• Due Date (text, required)
• Weeks Pregnant (number, required)
• Pregnancy Status (dropdown selection, required) — options: Low Risk, Moderate Risk, High Risk
• Multiple Pregnancy (twins etc) (multiple choice, required) — options: Yes, No
• Conditions Present (checkboxes, optional) — options: Gestational Diabetes, Preeclampsia, Placenta Previa, Cervical Insufficiency, Pre-Term Labor Risk, Hypertension, None
• Previous Pregnancy Complications (multiple choice, required) — options: Yes, No
• Currently on Bed Rest (multiple choice, required) — options: Yes - Partial, Yes - Full, No
• Cleared for Moderate Exercise (multiple choice, required) — options: Yes, No, With Restrictions
• Exercise Restrictions or Modifications (long text, optional)
• Provider Signature Obtained (multiple choice, required) — options: Yes