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/ THERAPIST’S STATEMENT
(To be completed by Health or Educational Professional other than M.D.)
Date: _______________
Participant’s Name:______________________________________________________________ Date of Birth:___________________
Address:___________________________________________________________________________________________________
Name of Parent/Guardian/Adult Caregiver, if any:____________________________________________________________________
Diagnosis:_______________________________________________________________ Date of onset:________________________
Current Therapy(Last treatment, date, remarks):_____________________________________________________________________
Current Medications:_________________________________________________________________________________________
Please indicate if the client/student 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 ? NoPlease indicate any special precautions____________________________________________________________________________
Name of Health/Education Professional:_______________________________________ Specialty/Licensing:____________________

PARTICIPANT’S MEDICAL HISTORY AND THERAPIST’S STATEMENT 
Participant’s Name:__________________________________________________________________________________________ 
Physical Function Assessment(mobility skills, range of motion, etc.)____________________________________________________ 
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Psycho/Social Function (i.e. emotional/mental health, behavioral issues, support systems, etc.) ______________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Concerns/potential safety issues in a farm or therapeutic riding setting?_________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________ 
Therapeutic/Educational Goals? Include goals that might be addressed within the framework of a therapeutic riding lesson:________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

THERAPIST’S or EDUCATOR’S STATEMENT
Unless otherwise noted in this form, to my knowledge there is no reason why this person cannot participate in supervised equestrian and outdoor activities. 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. 
Therapist Name (Please Print)________________________________________________________________ Therapist Signature:______________________________________________ Date____________________ Address_______________________________City________________________ State_______Zip_________ Phone: __________________________________ Secialty/Licensing:________________________________ State/Federal License Number, if applicable:____________________________________________________ 

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

Dear Therapist, Health Professional, or Educator, 
One of your clients/students has applied to receive therapeutic riding instruction at Reins From Above Therapeutic Riding Center, Inc. this year. Please fill out the attached form to the best of your ability and answer all of those questions which fall within your area of expertise or about which you have some pertinent information. Your input will help us to decide whether this person will benefit from therapeutic riding and/or establish goals for a therapeutic riding plan.  If you have any questions about this form, please call one of our instructors at 919-631-9294. 
Information for Therapist 
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