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ANTENATAL HYDROTHERAPY CHECKLIST

Patient Name:
Expected due date:
Parity:

DOB:

YES

NO

*Are you less than 16 weeks pregnant?


*Have you been diagnosed with diabetes? What type?
#Do you suffer any unstable cardiac conditions?
#Do you have hypo/hypertension? (if pregnancy induced)
Are you prone to fainting?
#Have you had any persistent bleeding/rupture of
membranes?
#Do you have restrictive lung disease?
Do you have asthma/bronchitis?
#Have you had any signs of early labour this pregnancy?
Do you have any open wounds/cuts?
Are you aware of any other problems during this pregnancy?
Do you smoke?
Do you have any infectious skin conditions?
Have you had any orthopaedic surgeries in the past?
*Do you have epilepsy?
Are you allergic to chlorine?
Are you currently taking any medications?
#absolute contraindication

*relative contraindication

Comments (if answered yes for any of above questions:


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Overall risk for Hydrotherapy

HIGH / MEDIUM / LOW

Does the patient have a fear of water?


Can the patient swim?
Does the patient require medical clearance?
If yes: Medical clearance obtained?
Signature:

Print name:

Yes/No
Yes/No
Yes/No
Yes/No
Date: