Medical and Client History

MEDICAL AND CLIENT HISTORY

This form must be updated annually and submitted with required signatures. All forms must have required signatures and be returned to Rhythms of Grace - prior to participating
Client Name*
Date of Birth

MonthDayYear
Date
Height
feet and inches
Weight
lbs
Gender
Primary Diagnosis
ICD Code
Diagnosis ONSET (please check one):

BirthChildhoodAdolescenceAdulthood
Diagnosis ONSET Date (if known)

MonthDayYear
Date
Secondary Diagnosis
Tertiary Diagnosis
CLIENT IS (check all that apply)

VerbalHearingVerbal AssistedHearing AssistedNon-VerbalDeafSeeingAmbulatorySeeing with assistAmbulatory AssistedBlindNon Ambulatory
PLEASE LIST ALL CURRENT MEDICATIONS
CURRENT/PREVIOUS THERAPIES
RHYTHMS OF GRACE GOALS for IMPROVED DAILY LIVING SKILLS
RIDING EXPERIENCE (check all that apply)

No Prior Riding ExperienceRiding Experience at Rhythms of GraceRiding Experience at Other Riding CenterRides with Side Walker SupportRides Independently
REQUIRED SIGNATURE OF CLIENT OR PARENT/GUARDIAN OF DEPENDENT PARTICIPANT*

Clear
DATE SIGNED*

MonthDayYear
Date

MEDICAL AND CLIENT HISTORY Please indicate if participant has or has had a history of the following by checking yes or no.

If Brace exists, When Was Last X-Ray Date

MonthDayYear
Date
If Seizures occur, Are They Controlled?
When Was Last Seizure Date

MonthDayYear
Any new seizures must be comunicated to Rhythms of Grace immediately.
If Scoliosis, What is Degree and Type?
Should be Empty: