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Aquanatal Hydrotherapy Questionnaire

Name:
DOB:..
Telephone number:..
(Preferably mobile number as we text/ring you in the event of a class cancellation.)
Email address:.
Next of Kin (name and Number)

..
How did you hear about us?.........................................................................
How many weeks pregnant are you? ...
When is your expected date of delivery? .
Do you have pregnancy related pain? ..
What brings on your pain? ...
What eases your pain? .
If you are unable to attend please could you let us know otherwise we are required to charge for the
class.
SignatureDate
Staff use:Date Started
Checklist shown to Physiotherapist
Shown round facilities
Phone number and email entered on Aqua phone