Front Range Exceptional Equestrians
PO Box 272452
Ft, Collins, CO 80527-
Phone (970)221-
RIDER'S MEDICAL HISTORY/PHYSICIAN'S CONSENT
Today’s Date_________________
Participant's Name _______________________________________________________
Participant's Birthdate _______________Contact Phone _________________________
Residence Address _______________________________________________________
City, State, ZIP __________________________________________________________
Mailing Address (Indicate if Same as Residence) _______________________________
City________________________________________State________________ ZIP ____
**This Section to be Completed by the Primary Care Physician**
Primary Diagnosis/Disability________________________ Patient’s Current Height_______ Weight______
Medications:_______________________________________________________________
If Diagnosis is Down Syndrome, rider must have cervical x-
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Does the patient have Seizures? Y N Type?______________ Controlled? Y N Date of last _______________
Does the patient have a Shunt? Y N Date of last Revision__________________
Please indicate any past or present special needs in any of the following areas:
__Auditory impairment __Learning disability __Chronic pain
__Speech impairment __Mental impairment __Spinal injury Level:_____
__Visual impairment __Psychological/ Emotional impairment __Laminectomy/fusion Level_____
__Sensory/ Tactile Defensiveness __Hydrocephalus __Spinal abnormality
__Allergies/asthma __Cardiac disease __Osteoporosis
__Pulmonary disease __Circulatory problems __Cranial defects
__Diabetes __Hemophilia Other:____________________
__Amputation __Subluxating/dislocating joints Other:____________________
__Fractures __Arthritis/joint disease Other:____________________
__Scoliosis Degree and type_________________________________________________
__Kyphosis/lordosis: Degree and type_________________________________________
__Recent or Prospective Surgery_____________________________________________
Patient achieves mobility by (check all that apply): ___Independent ambulation ___Wheelchair ___Walker
___Electric wheelchair ___Crutches ___Braces ___Cane Other _____________________
Type(s) of prostheses/orthotics used by patient:
Are there any other special precautions or needs of this patient you would like to advise us of at this time?
Given the above diagnosis and medical information, this person is not medically precluded from participation in equine assisted activities. I understand Front Range Exceptional Equestrians will weigh the medical information given against the existing precautions and contraindications. Therefore I refer this person to Front Range Exceptional Equestrians for ongoing evaluation to determine eligibility for participation in equine assisted activities.
Signature of Physician______________________________________________ Date________________
Physician's Name (please Print)_______________________________________________
Office Phone Number_______________________________________________________
Office Address _____________________________________________________________
City_________________________________. State ________ZIP____________________
CONTRAINDICATIONS and PRECAUTIONS to Therapeutic Horseback Riding
Any prospective therapeutic riding client having any of the following contraindications may not be allowed to participate in riding classes due to the risk of severe injury or death because of their condition. Any riding client having any of the following precautions/ contraindications must be evaluated to determine if a safe and beneficial riding experience can be provided for them. All clients must have their physician’s permission to participate.
Contraindications
ORTHOPEDIC
Coxa arthrosis (degeneration of hip joint, hip dislocation, subluxation, dysplasia with significant restriction or asymmetry of hip abduction and ROM)
Pathological fractures
Osteoporosis—moderate to severe
Spinal fusion-
Atlantoaxial Instability (See note below)
Spinal Instability producing excessive uncontrolled head and neck movements
Internal Spinal Stabilization Devices
Structural Scoliosis greater than 30 degrees
NEUROLOGIC
Spina Bifida (Hydromyelia, Chairi II Malformation, Tethered Cord)
Spinal Cord Injury above T6
Seizure Disorders (Uncontrolled Grand Mal type)
Hydrocephalus/Shunt with poor head control
Complete quadriplegia secondary to spinal injury
MEDICAL/SURGICAL
Acute arthritis Also, any client / rider the staff is not completely comfortable, competent,
Acute Multiple Sclerosis and safe working with or who demonstrates grossly disruptive behavior.
Agitation with severe confusion
Recent surgery
Anti-
CVA secondary to unclipped aneurysm or similar conditions
Open decubital ulcer/wound on weight bearing surface
Excessive kyphosis, lordosis or hemi vertebrae with decreased spinal mobility
Drug dosages causing physical symptoms
Unstable spine for any reason
Precautions
All conditions listed above can also fall into this category depending of the severity of the condition and current treatment. Each client/rider will be evaluated on an individual basis to determine if a safe and beneficial riding experience can be provided for them. In addition, the following conditions should also be considered precautions to riding therapy:
Allergies/ Asthma (horse hair, dust, etc.) Obesity
Abnormal fatigue Peripheral vascular disease
Age-
Behavior Varicose veins
Cancer Recent surgery
Diabetes Substance abuse
Hypertension Recent dorsal rhizotomy (3 months-
Heart /cardiac conditions Skin grafts
History of skin breakdown Sensory deficits
Incontinence /Indwelling catheters
** All riders with Down Syndrome must be examined by a physician knowledgeable about
Atlantoaxial instability (AAI). The exam must include full extension and flexion
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