BABY SWIMMING MEDICAL FORM

Details on this form are entirely confidential and are for personal records only.

Name: Igehi saqina/ryan prima Age:

Babys Name: Almeera sabhira kinnisa Male / Female:
Babys Date of birth: 16 juli 2016 Babys Due Date:
Occupation: Doctor/BUMN
Address: New serpong estate E-5, ciater
serpong, tangerang selatan
Tel.: Work: 021 - 75879298 Home: 021-5381680
Mobile: 081210919984/0811195382
Email: Igehi.saqina@gmail.com

Other children + ages -

Please give details of past or present injuries or problems (parent or baby)

10 days after she born, she gets bronkopneumonia she has to gets the theraphy treatment with medication in hospital in every
2 times/month & nebulazier every day in home. After 6 month shes getting better n stronger. I still bring her to gets control in
her pediatric every 3 month, coz sometimes she still gets hard to breath when ungood weather.

Are you or your baby presently on any medication (please give details)
When the astma (hard to breath) comes she gets nebulazier with Nacl 3cc+flexotide 1 ml + ventoline 1ml
(3 times a day every 8 hour)

Relevant labour / birth details / did your baby need special care:
-

Any further information you would like to make us aware of

so far is good

I take full responsibility over the health of my baby and myself in the swimming sessions and should there be any medical
change I will inform the Birthlight teacher.

Signed: Date: