Reins From Above Therapeutic Riding Center, Inc.
841 Wiggins Road
Angier, NC 27501
Phone: 919-631-9294
Website: www.reinsfromabove.org

PARTICIPANT’S MEDICAL HISTORY AND 
PHYSICIAN’S STATEMENT
(To be completed annually by Primary Physician)

DATE:
Participant’s Name:______________________________________________________________ Date of Birth:___________________
Address:____________________________________________________________________________________________________
Height:____________________ Weight:________________
Name of Parent/Guardian/Adult Caregiver, if any:_____________________________________________________________
Diagnosis:_______________________________________________________________ Date of onset:________________________
**For persons with Down Syndrome: ? Negative Cervical X-ray for Atlantoaxial Instability  X-ray Date:________________
? Negative for clinical symptoms of Atlantoaxial Instability. 
Tetanus Shot ? Yes, Date: _______________ ? No 
Seizure Type_________________________Controlled____________________________________Date of last seizure____________ Medications:_________________________________________________________________________________________________ 
Precautions for outdoor activities? (Allergies, sun/heat sensitivity, asthma, etc.)_____________________________________________ 
Please indicate if patient has a problem and/or surgeries in any of the following areas by checking yes or no.  If yes, please comment. 
Areas 	Yes 	No	 Comments 	
Auditory 				
Visual 				
Speech 				
Cardiac 				
Circulatory 				
Pulmonary 				
Neurological 				
Muscular 				
Orthopedic 				
Allergies 				
Learning Disabilities 				
Mental Impairment 				
Psychological Impairment 				
Other 				

Mobility: Independent Ambulation ?Yes  ? No;   Crutches ? Yes ? No;  Braces ? Yes ? No Wheelchair ? Yes ? No
Please indicate any special precautions____________________________________________________________________________

PHYSICIAN’S STATEMENT

Participant’s Name:_____________________________________________________________________________________________________________ 
PHYSICIAN’S STATEMENT
To my knowledge there is no reason why this person cannot participate in supervised equestrian and outdoor activities. However, I understand that Reins From Above Therapeutic Riding Center may contact me to discuss this information and will weigh the medical information above against the existing precautions and contraindications. I concur that a review of this person’s abilities/limitations by a licensed/credentialed health professional (e.g. PT, OT, Speech, Psychologist, etc.) may be helpful in the implementing of an effective equestrian program. 
Physician Name (Please Print)_______________________________________________________________ 
Physician Signature:______________________________________________ Date____________________ 
Address________________________________City_______________________State_______Zip_________ 
Phone: __________________________________________________________________________________ 
Information for Physician 
The following conditions, if present, may represent precautions or contraindications to therapeutic horseback riding. Therefore when completing this form, please note whether these conditions are present, and to what degree. 

Orthopedic
Spinal Fusion
Spinal Instabilities/Abnormalities
Atlantoaxial Instabilities
Scoliosis
Kyphosis
Lordosis
Hip Subluxation and Dislocation
Osteoporosis
Pathologic Fractures
Coxas Arthrosis
Heterotopic Ossification
Osteogenesis Imperfecta
Cranial Deficits
Spinal Orthoses
Internal Spinal Stabilization Devices
	Medical/Surgical
Allergies
Cancer
Poor Endurance
Recent Surgery
Diabetes
Peripheral Vascular Disease
Varicose Veins
Hemophilia
Hypertension
Serious Heart Condition
Stroke (Cerebrovascular Accident)
	
Neurologic
Hydrocephalus/shunt
Spina Bifida
Tethered Cord
Chiari II Malformation
Hydromyelia
Paralysis due to Spinal Cord Injury
Seizure Disorders
	Secondary Concerns
Behavior Problems
Age under 2 years
Age 2-4 years
Acute exacerbation of chronic disorder
Indwelling catheter
	
Please complete forms and send to:
Reins From Above Therapeutic Riding Center, Inc.
86 Polenta Road
Smithfield, NC 27577