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:
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:
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.
Physician's Name:
Physician's Signature:
Address:
City: State: Zip:
Phone: Date:
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