Greenlock Therapeutic Riding
Center
Participant’s
Application and Health History
GENERAL INFORMATION
Participant:
_____________________________________Parent/Guardian:
_________________________________________
DOB: ______________ Height: ____________Weight:
__________Gender: M F
Address:
______________________________________________________________________________________________
Email
Address:_________________________________________________________________________________________
Phone: _________________________Daytime phone (cell or
work): ______________________________________________
School/Employer:
_______________________________________________________________________________________
Parent/legal Guardian: ___________________________________________________________________________________
Address (if different from above):
___________________________________________________________________________
Funding source: Self_________ Other (specify):
_______________________________________________________________
PLEASE NOTE:
Greenlock TRC does not bill your insurance carrier for therapy services
rendered.
Medical Diagnosis:
_____________________________________________Date of Onset:
_________________________
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Y |
N |
Comments |
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Vision |
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Hearing |
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Sensation |
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Communication |
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Heart |
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Breathing |
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Digestion |
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Elimination |
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Circulation |
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Emotional/mental health |
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Behavioral |
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Pain |
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Bone/joint |
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Muscular |
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Allergies |
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Medications (including over-the-counter and prescription,
with NAME, DOSE, FREQUENCY):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Does the participant:
Communication |
Y |
N |
Comments |
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Imitate sounds after hearing them? |
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Gesture appropriately to indicate
yes, no, or want? |
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Says or signs 0-9 words? |
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Says or signs 10-24 words? |
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Says or signs 25-100 words? |
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Says or signs 100+ words? |
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Use phrases of 2 words? |
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Speak/sign in full sentences? |
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Uses phrases/sentences containing
but/or? |
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Spontaneously relate experiences in
detail? |
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Express ideas in more than one way? |
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Listen attentively to directions? |
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Follow instructions requiring an
action and an object? |
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Point accurately to one or more body
parts? |
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Indicate a preference when given a
choice? |
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Follow instructions with multiple
parts? |
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Recite all letters of the alphabet? |
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Print or write name? |
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Demonstrate understanding of the
function of money? |
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Daily Living Skills |
Y |
N |
Comments |
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Indicate anticipation of feeding on
seeing bottle or food? |
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Eat solid food? |
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Drink from bottle/cup/glass
unassisted? |
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Feed self with a spoon or fork? |
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Demonstrate that hot things are dangerous? |
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Look both ways before crossing a
road/street? |
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Indicate wet diapers? |
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Indicated soiled diapers? |
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Urinate in potty-chair or toilet? |
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Defecate in potty-chair or toilet? |
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Toilet trained during the day? |
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Toilet trained during the night? |
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Brush teeth without assistance? |
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Cover mouth and nose when
sneezing/coughing? |
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Remove pieces of clothing without
assistance? |
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Put shoes on correct feet without
assistance? |
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Fasten all fasteners? |
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Dress self completely? |
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Put own possessions away when asked? |
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Help with chores as asked? |
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Demonstrate understanding of the
clock? |
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Socialization |
Y |
N |
Comments |
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Respond to voice of caregiver? |
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Show interest in novel objects or new
people? |
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Express two or more recognizable emotions
like pleasure, fear, sadness or distress? |
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Imitate simple adult movements like
clapping or waving in response to a model? |
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Play with toys or objects alone? |
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Play with toys or objects with
others? |
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Play simple interaction games with
others? |
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Engage in make-believe activities
alone? |
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Engage in make-believe with others? |
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Imitate adult phrases heard on
previous occasions? |