Clearance Form ClientName *Client’s Birthdate *Baby’s due date *Does your client have any of these conditions?Ruptured membranes or premature labour *YesNoPregnancy-induced hypertension or pre-eclampsia *YesNoIncompetent cervix *YesNoPersistent second or third trimester bleeding *YesNoPlacenta previa *YesNoPossible intra-uterine growth restriction *YesNoMultiple pregnancy (e.g. twins/triplets) *YesNoUncontrolled Type I diabetes, hypertension, thyroid disease *YesNoHistory of miscarriage or premature labour *YesNoAnaemia or iron deficiency (Hb < 100 g/L) *YesNoMalnutrition or eating disorder (anorexia, bulimia) *YesNoAny cardiovascular or respiratory disease (e.g. chronic hypertension, asthma) *YesNoOther significant medical condition(s) *YesNoPlease specify *Physical Activity RecommendationI hereby approve Aquanatal® exercise programs for my client *[Insert Client Name]Name of healthcare provide *Additional Comments *AddressTelephone *Signed *Date *Send Message
