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Client Information
& PAR-Q Form

This research is being conducted with the aim to find ways to give you the best service during your aqua yoga therapy sessions. Your information is important to help to happen. All the information you provide is kept confidential,

Full name

Address

Date of Birth * required

Due date * required

Are you in good health? * Required

Yes

No

Email

Phone

Town/City

Postcode

Emergency Contact

Emergency Contact Number

Where did you hear about Lotus Aqua?

In the past, have you experienced a miscarriage in an earlier pregnancy? * Required

Yes

No

In the past, have you experienced any other pregnancy complications? * Required

Yes

No

If you have answered YES to the last two questions above, please explain

During this pregnancy, have you experienced any of the following:

Bleeding from the vagina (including spotting)

Marked fatigue

Unexplained faintness/dizziness

Unexplained abdominal pain

Sudden swelling of ankles, hands or face

Persistent headaches or problems with headaches

Swelling, pain or redness in the calf of one leg

Absence of foetal movement after 6th month

Failure to gain weight after 5th month

Ruptured membrane premature labour

Persistent second or third trimester bleeding

Placenta Previa or low lying placenta

Pregnancy induced hypertension or pre-eclampsia

Incompetent cervix

Evidence of intrauterine growth restriction

High-order pregnancy (e.g triplets)

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

A history of spontaneous abortion or premature labour in previous pregnancies

Asthma

Anaemia or iron deficiency

Malnutrition or eating disorder

Twin Pregnancy after 28th week? * Required

Indentical

Non-identical

N/A

Any other unlisted health or pregnancy related conditions? Please specify * Required

Yes

No

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 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 have read and agree to the Terms & Conditions as provided by Lotus Aqua

I agree

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

WhatsApp Groups: Do you give consent to be added to a WhatsApp group with those on your course? *

I consent

I do not consent

Photography: Do you give consent for photography to be taken of you to be solely used for social media and marketings purposes by Lotus Aqua? *

I consent

I do not consent

Full name

Today's date

Thanks for submitting!

Let's talk

Have a question or want to book on? Let me know!

hayley@lotus-aqua.co.uk

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First Name

Last Name

Phone

Email

Message

Thanks for getting in touch!

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