Dreams Go On with High Hopes
Therapeutic Horseback Riding program
RR 2 Box 351
Hollidaysburg, PA 16648
MEDICAL REPORT
Rider: ______________________________________ Date: ___________________
Date of Birth: ________________________________ Sex: ____________________
Height: __________________________ Weight: ____________________________
Pulse: ___________________________ Blood Pressure: _______________________
Diagnosis and Medications (type, purpose, dose):
______________________________
_______________________________________________________________________
Allergies: ______________________________________________________________
If Down’s Snydrome, Atlantoaxial Dislocation?: YES ______ NO _____
Cervical X ray for ADC: Positive _____ Negative _____ Date: __________________
(Required for program acceptance)
_______________________________________________________________________PROBLEM YES NO IF YES, DESCRIBE:__________________
Auditory
Impairment
________________________________________________________________________
Learning
Disability
________________________________________________________________________
Mental
Impairment
________________________________________________________________________
Psychological
Impairment
________________________________________________________________________
Speech
Impairment
________________________________________________________________________
Visual
Impairment
________________________________________________________________________
Circulatory
PROBLEM YES NO IF YES, DESCRIBE:__________________
Pulmonary
________________________________________________________________________
Neurological
________________________________________________________________________
Seizures Type: Controlled:
Date of Last Seizure:
________________________________________________________________________
Hydrocephalus Shunt:
________________________________________________________________________
Sensory Loss
________________________________________________________________________
Muscular
(contractures)
________________________________________________________________________
Skeletal (spinal
column injury,
joint problems,
scoliosis, kryphosis, etc.
Medical History: List any medical problems not listed above:
Mobility Status: Ambulatory? YES _____ NO _____ Describe:
Prosthetics/orthodontics:
Type:
Purpose:
Please describe additional information or special precautions that might help us to work with this Rider:
RECOMMENDATION:
________ YES, this patient is a suitable candidate for Dreams Go On Therapeutic
Horseback Riding Program
________ NO, I do not recommend this patient be involved in horseback riding
Physician’s Name: _______________________________________________________
Physician’s Signature: _____________________________________________________
Physician’s Address/Phone: ________________________________________________
Please return to Dreams Go On RR 2 Box 351, Hollidaysburg, PA 16648 OR Debbie Kelly, Rider Coordinator 1006 Valley View Blvd., Altoona, PA 16602 As Soon As Possible. Thanks
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