Aquanatal with Puddle Ducks Lincolnshire

First Name *

Surname *

Date of Birth *

Baby's due date *

First line of your address *

Town *

Postcode *

Contact Number

Email Address *

Doctor's name, address and phone number *

Emergency contact number *

Emergency contact name *

Please answer the questions below. The questionnaire will determine if you need to obtain your Doctors or Midwives written permission before beginning swimming. Do any of the following apply to you? Please read the questions carefully and answer each one 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 tick any of the questions below, then you are required to obtain your Doctor's 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.

Premature birth or threatened miscarriage *

Premature birth Threatened miscarriage No

Previous miscarriage(s) after 12 weeks of pregnancy *

Yes No

The fetus is small at the respective stage of your pregnancy *

Yes No

Leaking amniotic fluid *

Yes No

Spotting or bleeding after 12 weeks of pregnancy *

Yes No

Placenta Praevia *

Yes No

Cervical sutures *

Yes No

Dizzy spells caused by low blood pressure (after 12 weeks of pregnancy) *

Yes No

High blood pressure *

Yes No

Increased heart rate

Yes No

Decreased heart rate

Yes No

Chest pain brought on by physical activity *

Yes No

Heart or lung problems

Heart problems Lung problems No

Diabetes *

Yes No

Epilepsy *

Yes No

Low levels of iron in the blood (Severe Anaemia) *

Yes No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes No

Do you know of any other reason why you should not partake in swimming? *

Please also complete the following questions. If you answer YES to any of the following questions, you do not need a medical note however you are required to discuss your condition with your Aquanatal teacher to ensure that you understand the implications of certain exercises.

Are you asthmatic?

Yes No

Bone, joint or muscle problems (for example back, knee or hip) that could be made worse by a change in your physical activity?

Yes No

Do you suffer or have you suffered from Pelvic Girdle Pain (PGP), also known as Symphis Pubis Dysfuntion (SPD)?

Yes No

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

Where did you hear about us? *

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Aquanatal with Puddle Ducks Lincolnshire

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