Medical History

PARTICIPANT'S MEDICAL HISTORY & PHYSICIAN'S STATEMENT

Participant:

DOB:

Height:

Weight:

Address:

Diagnosis:

Date of On-Set:

Past/Prosective Surgeries:

Seizure Type:

Controlled:

Date of Last Seizure:

Shunt Present:

Date of Last Revision:

Special Precautions/Needs:

Mobility: Independent Ambulation:

Assisted Ambulation:

Wheelchair:

Braces/Assistive Devices:

For those with Down Syndrome:

AtlantoDens Interval X-rays, Date:

Result:

Neurological Symptoms of AtlantoAxial Instability:

Please indicate current or past special needs in the following systems/areas, including surgeries:

Comments

Auditory

Visual

Tactile Sensation

Speech

Cardiac

Circulatory

Integumentary/Skin

Immunity

Pulmonary

Neurologic

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. I understand that the NARHA center will weigh the medical information given against the existing precautions and contraindications. Therefore, i refer this person to the NARHA center for on-going evaluation to determine eligibility for participation.

Name/Title: _______________________________________________________________ MD DO NP PA Other ___________

Signature: ________________________________________________________________

Date: ____________________

Address: ___________________________________________________________________________________________________

Phone: ( ) _______________________________________________

License/UPIN Number: _______________________

Please print this form and bring it to your first/next lesson. Thank you.