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Aquatic Physical Therapy & Beyond, LLC
Pool and Spa Questionnaire 

           
 
Name:                 

1. Are you taking any antibiotics, have any infections or running a fever at this time? 

        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: 
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 patientís.
 
   
 
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.
           
                   
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.
           
                   
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
           

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:_________________________

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