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Antenatal Form

This antenatal health screening form collects contact and medical information from expectant mothers. It asks for the mother's name, address, due date, contact details, emergency contacts, doctors' information, midwives' information, medical history, ability to swim, special needs, current medications, medical conditions, problems in the current pregnancy, and risks. The form notes that the instructor will discuss it before the first class and honesty is needed for safety. It requires signatures from the mother and instructor.

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tami_web2
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
571 views1 page

Antenatal Form

This antenatal health screening form collects contact and medical information from expectant mothers. It asks for the mother's name, address, due date, contact details, emergency contacts, doctors' information, midwives' information, medical history, ability to swim, special needs, current medications, medical conditions, problems in the current pregnancy, and risks. The form notes that the instructor will discuss it before the first class and honesty is needed for safety. It requires signatures from the mother and instructor.

Uploaded by

tami_web2
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ANTENATAL HEALTH SCREENING FORM

Name of Adult:

Address:

Postcode:

Due Date:

Telephone number: Mobile:

Email address:

Emergency contact: Relationship:

Telephone number: Mobile:

Doctors name and contact:

Midwifes name and contact:

Medical History Your instructor will discuss this form with you before your first class. Please be honest as there are guidelines in place for the safety of you and your baby.

Details:
Can you swim? / What is your ability level?

Details:
Do you have any special needs?

Details:
Are you taking any medication? :

 Thrombosis  High Blood Pressure  Low Blood Pressure  Diabetes


Do you have any serious medical conditions?  Epilepsy  Heart Condition  Asthma  Chronic Bronchitis
Please tick all that apply.
 Other:

Other problems?  Back or joint pain  Pubic or groin pain  Pain on walking  Recurrent miscarriages

 Multiple pregnancy (Twins etc)  Low lying placenta (placenta praevia)


In THIS pregnancy have you had any of the  bleeding or loss of Amniotic fluid  Early contractions or pre-term labour
following?
 Sensitivity to Chlorine  Fear of water

If you answered YES to one or more questions, you must check with your doctor before taking part.

ASSUMPTION OF RISK
I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Signature: Date:

INSTRUCTOR USE ONLY

Any advice given to client:

Signature:

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