Aquanatal Health Questionnaire

Full name *

D.O.B *

Full address including postcode *

Baby due date *

Email address *

Telephone number *

Doctor’s Name, address and telephone number *

Emergency contact name and telephone number *

Please answer the questions below. The questionnaire will determine if you need to obtain your Doctors or Midwives written permission before beginning swimming. Please read the statements carefully and answer honestly. Please speak to your teacher if there is anything that concerns you. If you knowingly give incorrect information the Teacher and Puddle Ducks can bear no responsibility for any resultant injury or pain. If you answer select any of the following, then you are required to obtain your Doctors written permission BEFORE attending a session. Due to insurance reasons, waivers of consent are not permitted. Doctors may charge for a ‘fit to exercise’ certificate – this charge cannot be passed onto Puddle Ducks. *

If you have any of the following conditions, please select them. *

Asthmatic Bone, joint or muscle problems (for example back, knee or hip) that could be made worse by a change in your physical activity? Do you suffer or have you suffered from Pelvic Girdle Pain (PGP), also known as Symphis Pubis Dysfuntion (SPD)? None of the above

Please remember any physical activity should not be painful. If it hurts stop immediately and tell your teacher. *

Additional information

Data *

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Aquanatal Health Questionnaire

Aquanatal

Health Questionnaire

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