Hydrotherapy Consent Form
Patient First Name
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Patient Surname
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Date of Birth
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Email Address
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Contact Number
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Next of kin
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Next of kin phone number
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Source of referral (i.e.- Physio, Exercise Physiologist/ Self referred)
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Swimming Ability
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Confident
Not-confident
Swimmer
Non-swimmer
Assistance required getting in / out of the pool
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Independent
Requires assistance
Requires a manual aide
Contra-indications or precautions (PLEASE TICK IF ANY OF THESE APPLY
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Cardiovascular concerns (i.e. vascular disease, poor blood pressure control, cardiac surgeries)
Respiratory concerns (i.e. acute or chronic respiratory diseases, shortness of breath, respiratory tract infections)
Neurological Concerns (i.e. epilepsy/history of seizures and / or fits, swallowing difficulties)
Gastro-intestinal concerns (i.e. faecal incontinence, diarrhoea/gastroenteritis, colostomies)
Genito-unrary tract concerns (i.e. urinary tract infections, urinary incontinence, pregnancy)
Current infections (i.e. AIDS, HIV, Staph infections, chest infections, Hepatitis A, B and C)
Skin concerns (surgical / open wounds, rases, skin infections, chemical sensitivity, tinea)
Eye/ear concerns (visual impairments, hearing impairments, implants)
Other concerns (i.e. inflammatory conditions, heat-sensitivity, current cancer treatment, diabetes, lymphoedema)
NONE OF THE ABOVE
Signature
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Date
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