Greenlock Therapeutic Riding Center

55 Summer Street, Rehoboth, MA 02769

508-252-5814 - on the web at www.greenlock.org

Participant’s Medical History & Physician’s Statement

Participant: __________________________________________ DOB: _______ Height: ______ Weight: ____________

Address: _________________________________________________________________________________________

Diagnosis: _______________________________________________________ Date of Onset: ____________________

Past/Prospective Surgeries: ___________________________________________________________________________

Medications: ______________________________________________________________________________________

Seizure Type: ______________________________ Controlled: Y ____ N ____ Date of Last Seizure: __________

Shunt Present: Y ____ N ____ Date of last revision: ____________________________________________________

Special Precautions/Needs: ____________________________________________________________________________

Mobility: Independent Ambulation Y____ N____ Assisted Ambulation Y____ N____ Wheelchair Y____ N____

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:

	Y	N	Comments
Auditory
Visual
Tactile Sensation
Speech
Cardiac
Circulatory
Integumentary/Skin
Immunity
Pulmonary
Neurological
Muscular
Balance
Orthopedic
Allergies
Learning Disability
Cognitive
Emotional/Psychological
Pain
Other

To my knowledge, there is no reason why this person cannot participate in supervised equestrian activities. However, I understand that the NARHA center will weigh the medical information above against the existing precautions and contraindications. I concur with a review of this person’s abilities/limitations by a licensed/credentialed health professional (e.g. PT, OT, SLP, Psychologist, etc.) in the implementation of an effective equine activity program.

Name/Title: ________________________________________________ MD

Signature: ____________________________________________________________ Date: ____________________

Address: _________________________________________________________________________________________

Phone: ( )_______________________________ License/UPIN Number: ___________________________