Aquatic Physiotherapy Screening Form
Please complete the below information.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone number
*
Preferred contact method
Please Select
Phone
Email
Contraindications
If you select yes to any of the below options then aquatic physiotherapy is not suitable.
Unstable cardiac condition
*
Please Select
Yes
No
Resting angina/Shortness of breath at rest
*
Please Select
Yes
No
Unstable renal condition
*
Please Select
Yes
No
Medical instability (such as recent stroke)
*
Please Select
Yes
No
Vomiting/diarrhoea
*
Please Select
Yes
No
Chlorine sensitivity
*
Please Select
Yes
No
Bodyweight over 25 stone
*
Please Select
Yes
No
Fever/infection
*
Please Select
Yes
No
Precautions
If you select yes to any of the below options then aquatic physiotherapy may be for you however will need to discuss certain precautions we should make prior to starting.
Diabetes
*
Please Select
Yes
No
Cardiac history/ Blood pressure (high or low)
*
Please Select
Yes
No
Reduced lung function
*
Please Select
Yes
No
Epilepsy
*
Please Select
Yes
No
Known aneurysm
*
Please Select
Yes
No
Fragile skin
*
Please Select
Yes
No
Fear of water
*
Please Select
Yes
No
High rate of fatigue
*
Please Select
Yes
No
Open wounds/ulcers/Verrucas
*
Please Select
Yes
No
Contact lenses/grommets/hearing aids
*
Please Select
Yes
No
Behavioural problems
*
Please Select
Yes
No
Invasive tubes insitu
*
Please Select
Yes
No
Impaired sensation/vision
*
Please Select
Yes
No
Spondylolisthesis
*
Please Select
Yes
No
Urinary/faecal incontinence
*
Please Select
Yes
No
MRSA positive
*
Please Select
Yes
No
Bodyweight over 16 stone
*
Please Select
Yes
No
Pregnancy
*
Please Select
Yes
No
Are there any other health conditions that you feel are relevant, please list them below.
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What is your current level of mobility? (For example, can you walk unaided or do you need a walking stick or Zimmer frame).
*
Do you require any support to ascend/descend stairs to enter the pool? Please note, a hoist is available for entry into the pool if required.
*
*
I confirm that the information provided above is true and accurate.
Signature
*
Date
*
-
Day
-
Month
Year
Date
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