Physician Information Form

Please submit the following, or if you prefer, download the .pdf form, print and mail to:
Northland Therapeutic Riding Center
P.O. Box 1267
Kearney, MO 64060


Participant's Medical History and Physician's Statement
(To be completed by physician.)

Participant:

DOB: Height: Weight:

Home Address:

City: State: Zip:

E-mail:


Diagnosis:


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: + -

Neurological Symptoms of AtlantoAxial Instability:


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

Auditory
Yes No Comments:
Visual
Yes No Comments:
Tactile Sensation
Yes No Comments:
Speech
Yes No Comments:
Cardiac
Yes No Comments:
Circulatory
Yes No Comments:
Integumentary/Skin
Yes No Comments:
Immunity
Yes No Comments:
Pulmonary
Yes No Comments:
Neurological
Yes No Comments:
Muscular
Yes No Comments:
Balance
Yes No Comments:
Orthopedic
Yes No Comments:
Allergies
Yes No Comments:
Learning Disability
Yes No Comments:
Cognitive
Yes No Comments:
Emotional/Psychological
Yes No Comments:
Pain
Yes No Comments:
Other
Yes No Comments:


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 by a licensed/credentialed health professional (e.g. PT, OT, Speech, Psychologist, etc.) in the implementation of an effective equestrian program.

Participant's Name:

Participant's Signature:

Physician's Name:

Physician's Signature:

Address:

City: State: Zip:

Phone: Date:



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