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Client Information & PARQ Form

Full Name:

Email:

Phone:

Address

Town

Postcode

Date of Birth

Emergency Contact

Emergency Contact Tel No.

Due Date

1. Are you in good health?

Yes

2. In the past, have you experienced a miscarriage in an earlier pregnancy?

Yes

3. In the past, have you experienced any other pregnancy complications?

Yes

If you have answered YES to Q2 or 3, please provide details

During this pregnancy, have you experienced: 4.Marked Fatigue?

Yes

5. Bleeding from the vagina (including spotting)?

Yes

6. Unexplained faintness/dizziness?

Yes

7. Unexplained abdominal pain?

Yes

8. Sudden swelling of ankles, hands or face?

Yes

9. Persistent headaches, or problems with headaches?

Yes

10. Swelling, pain or redness in the calf of one leg?

Yes

11. Absence of foetal movement after 6th month?

Yes

12. Failure to gain weight after 5th month?

Yes

If you have answered YES to any of the above questions, please explain:

13. Do you currently have or suffer from ruptured membrane, premature labour?

Yes

14. Persistent second or third trimester bleeding?

Yes

15. Placenta Previa?

Yes

16. Pregnancy induced hypertension or pre-eclampsia?

Yes

17. Incompetent cervix?

Yes

18. Evidence of intrauterine growth restriction?

Yes

19. High-order pregnancy (e.g triplets)?

Yes

20. Uncontrolled Type 1 diabetes, hypertension or thyroid disease, other cardiovascular, respiratory or systemic disorder?

Yes

21. A history of spontaneous abortion or premature labour in previous pregnancies?

Yes

22. Asthma?

Yes

23. Anaemia or iron deficiency?

Yes

24. Malnutrition or eating disorder?

Yes

25. Twin Pregnancy after 28th week?

Yes

N/A

If YES to above question are they:

Identical?

Non-identical?

N/A

26. Any other unlisted health or pregnancy related conditions? Please specify

Yes

If you have answered YES to any of the above questions, please explain:

I hereby state that I have answered the above questions accurately and honestly

I agree

I confirm that I have discussed any health concerns raised above with my Health Care Provider and have been given full clearance from them to exercise in a pool environment. I agree I must notify Lotus Aqua of any changes to my health prior to each class commencing.

I agree

I agree that if there are any changes to my health or any unusual symptoms occur at any point, I will cease to participate and inform my Health Care Provider of these symptoms

I agree

I am happy to receive first aid during Lotus Aqua classes in case of sickness or injury and in rare circumstances I may be asked to assist with delivering first aid if another member becomes sick or suffers injury, under the supervision of Lotus Aqua.

I agree

I agree that I am voluntarily participating in Lotus Aqua classes which include gentle aerobic & water resistance exercises and stretching. I realise that my participation in these classes are done so at my own risk.

I agree

I have read and agree to the General Information, Terms & Conditions as provided by Lotus Aqua

I agree

I accept that classes are non refundable or transferrable, unless cancelled by Lotus Aqua

I accept

I understand that by inputting my name and dating the below boxes, will act as an electronic signature. By doing this and by paying the class fees, I am agreeing to Lotus Aqua's Terms and Conditions and the facility pool rules.

I agree

Full Name:

Date

WhatsApp Groups; At your request, Lotus Aqua is happy to arrange WhatsApp Groups for clients on the same courses to keep in contact. Please choose from the following options to give/not give consent for your Mobile Number to be shared with those on your course:

I consent

I do not consent

Photography; Lotus Aqua may at times ask to take photography, solely for promotional purposes on social media and/or marketing materials. Please select from the following options to give or not give your consent to photography being taken of you

I consent

I do not consent

Client Information & PARQ form last updated 16/05/2022

Privacy Statement

Lotus Aqua takes the protection of your data seriously.

Lotus Aqua only collects enough information for the purpose and needs of the business and at no time with your data be shared with external third parties, without your prior consent, unless there is a health and safety emergency.

All your data is stored in a password secure laptop and/or storage clouds.

Invoices will be stored electronically in accordance with HMRC accounting requirements and destroyed after 6 years.

All other personal data will be stored for insurance purposes and destroyed 12 months after your last class with Lotus Aqua.

Your contact details will not be used for marketing purposes.

Client Information & PARQ Form

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