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3 Aquatic Therapy Risk Assessment Screening (Contraindications) Form

Name of Patient *

First

Last

Date of Birth *

DD/MM/YYYY

GP / Treating Physician Name *

GP / Treating Physician Clearance Obtained *

Yes
No

Patient Weight *

If weight in excess of evacuation equipment limits booking will not be possible

Acute vomiting or diarrhoea *

Absolute Contraindication to pool use

Medical instability following acute episode (eg: CVA, DVT, PE, Status asthmaticus) *

Absolute Contraindication to pool use

Behavioural instability preventing safe pool use *

Absolute Contraindication to pool use

Proven chlorine allergy *

Absolute Contraindication to pool use

Resting Angina *

Absolute Contraindication to pool use

Shortness of breath at rest *

Absolute Contraindication to pool use

Uncontrolled cardiac failure or Paroxysmal nocturnal dyspnoea *

Absolute Contraindication to pool use

Acute systemic illness/pyrexia *

Absolute Contraindication to pool use

Open infected wounds *

Absolute Contraindication to pool use

Active cancer treatment *

Absolute Contraindication to pool use

Irradiated skin during course of radiotherapy *

Relative Contraindication to pool use If yes please give more details below

Known aneurysm *

Relative Contraindication to pool use If yes please give more details below

Repeated chest infections *

Relative Contraindication to pool use If yes please give more details below

Poorly controlled epilepsy *

Relative Contraindication to pool use If yes please give more details below

Unstable diabetes *

Relative Contraindication to pool use If yes please give more details below

Thyroid deficiency *

Relative Contraindication to pool use If yes please give more details below

Difficulty stabilising temperature *

Relative Contraindication to pool use If yes please give more details below

Fear of water *

Relative Contraindication to pool use If yes please give more details below

Behavioural problems *

Relative Contraindication to pool use If yes please give more details below

Incontinence of urine/faeces *

Relative Contraindication to pool use If yes please give more details below

Gross obesity *

Relative Contraindication to pool use If yes please give more details below

Controlled epilepsy *

Relative Contraindication to pool use If yes please give more details below

Haemophillia *

Relative Contraindication to pool use If yes please give more details below

Widespread MRSA *

Relative Contraindication to pool use If yes please give more details below

Hypertension/Hypotenstion *

Relative Contraindication to pool use If yes please give more details below

Renal Failure *

Relative Contraindication to pool use If yes please give more details below

Poor Skin integrity *

Relative Contraindication to pool use If yes please give more details below

Contact lenses/conjunctivitis/impaired vision *

Relative Contraindication to pool use If yes please give more details below

Grommets/Hearing aids/impaired hearing *

Relative Contraindication to pool use If yes please give more details below

Contagious viral condition *

Relative Contraindication to pool use If yes please give more details below

Contagious fungal condition *

Relative Contraindication to pool use If yes please give more details below

Tracheotomy *

Relative Contraindication to pool use If yes please give more details below

Early kidney disease *

Relative Contraindication to pool use If yes please give more details below

Colostomy bag or catheter use *

Relative Contraindication to pool use If yes please give more details below

Poor endurance *

Relative Contraindication to pool use If yes please give more details below

Medications *

Relative Contraindication to pool use If yes please give more details below

PEG/ Gastrostomy *

Relative Contraindication to pool use If yes please give more details below

Dysphagia / mouth closure ability *

Relative Contraindication to pool use If yes please give more details below

Impaired respiratory effort *

Relative Contraindication to pool use If yes please give more details below

Pain *

Relative Contraindication to pool use If yes please give more details below

Hip problems *

Relative Contraindication to pool use If yes please give more details below

Spinal rodding *

Relative Contraindication to pool use If yes please give more details below

Severe weakness *

Relative Contraindication to pool use If yes please give more details below

More Details of relative contraindications above *

Electronic Signature (name) *

Email *

Phone Number *

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