Health Screening Questionnaire

HEALTH SURVEY FORM and informed consent(This form must be completed by each swimmer using the pool) Name and Index ........................... Phone number is not .............................................. .......... E-mail Emergency contact name, address and telephone number is ........................................................ Your
Timeshare
Age (please tick) 25 25-35 35-45 45-55 55-65 65 +Please read the question and answer honestly as you can: -Please check the appropriate box, Yes or No YES NO



1 you on any medications that may affect you while swimming? If yes, please describe in detail ............................................ ............................................



2 Do you have an illness / disability? If yes, please describe in detail ............................................ ............................................





3 Do you have an injury or joint problems? If yes, please describe in detail ............................................ ............................................



4 Do you have any allergies? If yes, please describe in detail ............................................ ............................................





5 you are pregnant or have been pregnant within the last 6 months? If you answered yes to any of the questions, it is suggested that you seek medical approval prior to sailing. Although we make every effort to keep the session as safe and effective, as in any program, activity, there is always a potential risk of injury and I acknowledge that I participate at my own free will. PTO
Informed consent
I hereby declare that I have read, understood and answered honestly, to exercise medical examination form. Although we make every effort to keep the pool safe and enjoyable session, I participate in his will and as with any exercise program, there is always a potential risk of injury.

The name Naomi ...

pool, private, norwich, norfolk, uk, england, children's, parties