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:

    The best part of your day

    Now is the time to focus on your health and fitness.

    What our members say

     Jennifer Packard
    Jennifer Packard

    Whether you’re just starting out, trying to get back into a routine, or are feeling frustrated with your current regimen: Your fitness journey is your own. Don’t compare yourself to anyone else.

     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.