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

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_____________________________________