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Aquatic Physical Therapy & Beyond, LLC |
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| Name: | |||||||||
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1. Are you taking any antibiotics, have any infections or running a fever at this time? |
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| If Yes, please list and describe: | |||||||||
| 2. Do you have bowel or bladder problems? (dribbling, unable to control bowel or bladder? | |||||||||
| If Yes, please Explain: | |||||||||
| 3. Do you have any wounds or open skin areas? | |||||||||
| If Yes, please Explain: | |||||||||
| 4. Do you have any bandages or dressings at this time? | |||||||||
| If Yes, please Explain: | |||||||||
| 5. Do you have any tubes? (Example: feeding tube, catheter, GI tube) | |||||||||
| If Yes, please Explain: | |||||||||
| 6. Do you have any rashes? | |||||||||
| If Yes, please Explain: | |||||||||
| 7. Do you have normal blood pressure? | |||||||||
| If No, please Explain: | |||||||||
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PLEASE NOTE:
If during the course of your therapy, you develop ANY of these
symptoms, YOU MUST let your therapist know BEFORE you enter the pool/hot tub. It is URGENT that these symptoms be addressed before you enter the pool for your safety as well as the other patient’s. |
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| Swim or Float: I can swim. I don't swim, but I like the water. 1 don't like the water, but I'm willing to try. I want a therapist in the pool with me. |
To enter the Pool: I need the chair lift. I need help with the stairs. I can enter the ool on my own. |
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| Water Chemistry: I have never reacted to chlorine before. I am allergic to chlorine. |
History: I have been in a pool before. I have never been in a pool. I have been in a hot tub before. I have never been in a hot tub. |
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| To Get Ready for the Pool: I will bring my own help for changing. I do not need help changing. |
Hot Tub Heat - 100+ temperature. I am fine with heat. I son't do well with heat |
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I
have read and understand this form. I agree to abide by the rules of
the pool usage. I have been given the
opportunity to ask questions and
understand that I may ask questions at any time if I am not sure about
something.
| Patient Initials: Date: Patient Signature after printing:_________________________ |
Then Print This Form