Release forms - 3 of 4

RIDER'S MEDICAL HISTORY AND PHYSICIAN'S STATEMENT
to be completed annually

Information for Physician

The following conditions, if present, may represent precautions or contraindications to therapeutic horseback riding. Therefore, when completing this form please note whether these conditions are present and to what degree.
 
Orthopedic
Neurologic
 Medical / Surgical
Spinal fusion Hydrocephalus / shunt Allergies
Spinal Instabilities / Abnormalities Spina Bifida Cancer
Atlantoaxial Instabilities Tethered Cord Poor Endurance
Scoliosis Chiari II Malformation Recent Surgery
Lordosis Hydromelia Diabetes
Kyphosis Paralysis due to spinal
cord injury		 Peripheral Vascular Disease
Hip Subluxation and Dislocation Varicose Veins
Osteoporosis Seizure Disorders Hemophilia
Pathologic Fractures
Secondary Concerns
 Hypertension
Coxas Anthrosis Behavior problems Serious Heart Condition
Heterotopic Ossification Age - Under two years Stroke (Cerebrovascular
Accident)
Osteogenesis Imperfecta Age - two - four years  
Cranial Deficits Acute exacerbation
of chronic disorder
Spinal Orthoses
Internal Spinal Stabilization Devices Indwelling Catheter


Name: black line
Date of Birth: black line
Name of
Parent/Guardian:		 black line
Diagnosis: black line
Date of Onset: black line
 
Tetanus Shot:
Yes black line    No black line    Date: black line
 
Height black line    Weight black line
 
Seizure Type: black line
Controlled: black line
Date of Last Seizure black line
 
Medications: black line


Please indicate if a patient has a problem and or/surgeries in any of the following areas by checking yes or no. If yes, please comment.
Areas
Yes
No
 Comments
Auditory      
Visual      
Speech      
Cardiac      
Circulatory      
Pulmonary      
Neurological      
Muscular      
Orthopedic      
Allergies      
Learning Disability      
Mental Impairment      
Psychological Impairment      
Other      


Mobility
Independent Ambulation    Yes    No
Crutches Yes    No
Braces Yes    No
Wheelchair
Yes   
 No
Please indicate any special precautions: black line


For Persons with Down Syndrome:
Cervical X-ray for Atlantoaxial Instability:
Positive black line    Negative black line    X-ray Date: black line


To my knowledge there is no reason why this person cannot participate in supervised equestrian activities. However, I understand that the therapeutic riding center will weigh the medical information above against the existing precautions and contraindications. I concur with a review of this person's abilities / imitations by a licensed / credentialed health professional (e.g. PT, OT, Speech, Psychologist, etc.) in the implementing of an effective equestrian program.
Physician Name: black line (please print)
Physician Signature:  
Physician Stamp:  
Street Address: black line
City: black line
State & Zip: black line
Phone: black line
Date: black line


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Pal-O-Mine Equestrian, Inc. • 829 Old Nichols Road • Islandia, NY 11749