Therapeutic Equine Instruction Participant’s Medical History and Physician’s Statement

Therapeutic Equine Instruction Participant’s Medical History and Physician’s Statement

This form MUST be signed and dated by a MD, DO, NP, PA or other Medical Professional in the designated area at the bottom of this page
Participant: _________________________ DOB: ___ / ___ / ___ Height: _____ Weight: _____

Address: ________________________________________________________________

Diagnosis: _______________________________ Date of Onset: ___ / ___ / _____
Past/Prospective Surgeries: ________________________________________________________________
Medications: ________________________________________________________________

Seizure Type: ___________________Controlled: Yes No
Date of Last Seizure: ___ / ___ / _____
Shunt Present: Yes No Date of last revision: ___ / ___ / _____
Special Precautions / Needs: ________________________________________________________________
________________________________________________________________
Mobility: Independent Ambulation: Yes No Assisted Ambulation: Yes No Wheelchair: Yes No
Braces / Assistive Devices: ______________________________________________________________
For those with Down syndrome: AtlantoDens Interval X-Rays Date: __ / __ / __ Result: Positive Negative
Neurologic Symptoms of Atlanto Axial Instability: _________________________________________________
Please indicate difficulties, medical conditions and/or surgeries in any of the following areas below by checking Yes or No. If yes, please comment
Areas Yes No Comments
Auditory
Visual
Tactile Sensation
Speech
Cardiac
Circulatory
Integumentary / Skin
Immunity
Pulmonary
Neurological
Muscular
Balance
Orthopedic
Allergies
Learning Disability
Cognitive
Emotional / Psychological
Pain
Other

Given the above diagnosis and medical information, this person is not medically precluded from participation in equine assisted activities and/or therapies including riding. I understand that Prospect Riding Center will weigh the medical information given against the existing precautions and contraindications.

PHYSICIAN’S SIGNATURE:______________________________________________________
DATE: ___ / __ / ___

Clearly Print Name & Title:____________________________________________________________________________________________________________________________ License/UPIN Number
Address: ___________________________________________________________________________________________________________ Phone: (___) _________

Please Indicate: MD DO NP PA Other_____________________________________