Water Baby Health Form

Water Baby Infant Aquatics Health Form

First Name

Last Name

Email Address

Phone

 

Please answer yes or no for each condition.
If you answer yes, please explain below.
Has your child:

Been seen by a medical specialist?
YesNo

Heart murmor
YesNo

CPR
YesNo

Fever longer than one week
YesNo

Physical therapy
YesNo

Seizures
YesNo

Respiratory problems
YesNo

Bowel/bladder problems
YesNo

Gastro esophageal reflux
YesNo

Chronic illness
YesNo

A.D.D. learning disorder
YesNo

Speech therapy
YesNo

Lactose intolerance
YesNo

Ear infections
YesNo

Surgery
YesNo

Allergies
YesNo

Head injury/ loss of consciousness
YesNo

OT therapy
YesNo

Other therapy
YesNo

Asthma
YesNo

Ear tubes
YesNo

Further information about medical conditions:

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What our members say

 Jennifer Packard
Jennifer Packard

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 Terry Hall
Terry Hall

‘Can’t’ is no longer in my vocabulary, and I have a sense of pride in my ability to work toward a goal and not only achieve it, but often exceed it.