CONFIDENTIAL MEDICAL HISTORY

CONFIDENTIAL MEDICAL HISTORY
Clients Name (Participant)

First NameLast Name
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

DayMonthYear
Experience with horses

No experienceOccasional interactionsBasic horse experience on groundSome riding experienceHighly experienced, have owned horses or ridden 10yrs +
Client Profile
Are there any learning difficulties, mobility issues or other physical dynamics that will impact on participation? Please describe providing as much information as possible.
Is there any information about formal diagnosis you can share with us. Please describe providing as much information as possible.
Anything else that it is important for us to know? Please describe providing as much information as possible.
Does the participant experience any of the following?

AsthmaAllergic reactionsDiabetesHeart conditionBlood conditionRecent injuryEpilepsyPregnancyFaintingDizzinessBlackoutsMigraineDisabilityUneven pupilsBack injuryMedicationsOther
If you ticked "Other" please list.
Allergies - please describe and note reaction, treatment and prevention.
Medication - Is it necessary for the client to carry medication? Please describe medication and usage.
Last Tetanus immunisation (Year)
Year
Consent to medical attention

I authorise the therapeutic team to administer first aid and call an ambulance as deemed necessary. I will bear costs of ambulance.
Signature of Client (Participant)*
Signature of Legal Guardian (if under 18)
Privacy Statement 1998

By completing this form, you are suppling the provider with personal information about yourself. This information is needed to ensure your safety during your time with us. The provider is required to collect this information by our insurance company and by the department of Workplace Health and Safety. This information you provide will not be supplied to any other organisation or used for any other purpose that that which is stated above.
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CONFIDENTIAL MEDICAL HISTORY

Client Profile