HEALTH SCREENING QUESTIONNAIRE AND INFORMED CONSENT

(This form must be completed by each swimmer using the pool) Name & address………………………………………………………………………………………… …………………………………………………………………………………………………………….. Postcode………………………Contact Phone No’s……………………………………………….. Email address………………………………………………………………………………………….. Emergency contact name, address & phone no’s……………………………………………….. ……………………………………………………………………………………………………………..  Your occupation………………………………………………………………………………………… 

Timeshare slot:…………………………………………………………………………………………………………………

Age (please tick) under 25          25-35            35-45         45-55           55-65            65+

Please read the questions carefully and answer as honestly as you can:-

Please tick appropriate box, YES or NO                                                                YES       NO

1          Are you on any medication that may affect you during your swim? If YES, please give details……………………………………………………………………………. ……………………………………………………………………………………………………………..

2          Have you any illness/disabilities?                                                               If YES, please give details……………………………………………………………………………. 

……………………………………………………………………………………………………………..

3          Do you have any injuries or joint problems? If YES, please give details……………………………………………………………………………. ……………………………………………………………………………………………………………..

4          Do you have any allergies ? If YES, please give details……………………………………………………………………………. 

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5          Are you pregnant or have you been pregnant in the last 6 months?                                                                                                                                                                                                                                                                                                 If you have answered YES to any of the questions, it is suggested that you seek medical approval before commencing swimming.  Whilst every effort is made to keep the sessions both safe and effective, as with any programme of activity, there is always the potential risk of injury and I accept that I am participating of my own free will.   Name………………………………………….Signature……………………………………………… Date……………………………………………………………………………………………………….. PTO

Informed Consent

I hereby state that I have read, understood and answered honestly, the pre-exercise health screening questionnaire.  Whilst every effort is made to keep the swimming sessions safe and enjoyable, I am participating of my own free will and as with any exercise programme, there is always the potential risk of injury.