Physician Form

Healing Reins of Kentucky Physician Form
Physician Form- Physician's office MUST complete

Dear Healthcare Provider: Your patient    First Name*   Last Name*   is interested in participating in supervised equestrian activities. In order to safely provide this service, our operating center requests that you complete/update the Medical History & Physician's Statement. Please note that the following conditions may suggest precautions and contraindications to equine activities. Therefore, when completing this form, please note whether these conditions are present, and to what degree. If you have any questions or concerns regarding the patient's participation in therapeutic horseback riding, hippotherapy and horse related activities, please do not hesitate to contact the operating center.

*Required for Down Syndrome: Neurologic Symptoms of Atlantoaxial Instability:         Date

*An annual medical clearance from a licensed physician that includes a neurological exam that specifically denies any symptoms consistent with atlantoaxial instability (AAI) is required.
Patient weight during last exam:*
Height:*
Date of Last Exam:*

MonthDayYear
Date
Date of Onset: Date*
Diagnosis:*
The following conditions, if present, may represent precautions and contraindications to therapeutic horseback riding.

Please select below any of the following conditions present:

Orthopedic:

Y   Spinal Fusion
Y   Spinal Instabilities/Abnormalities
Y   Atlantoaxial Instabilities
Y   Scoliosis
Y   Kyphosis
Y   Lordosis
Y   Hip Subluxation & Dislocation
Y   Osteoporosis
Y   Pathologic Fractures
Y   Coxas Arthrosis
Y   Heterotopic Ossification
Y   Osteogenesis Imperfecta
Y   Cranial Deficits
Y   Spinal Orthoses
Y   Internal Spinal Stabilization Devices

Neurologic:
Y   Acute exacerbation of chronic disorder
Y   Hydrocephalus/shunt
Y   Chiari II Malformation
Y   Spina Bifida
Y   Tethered Cord
Y   Hydromyelia
Y   Paralysis due to Spinal Cord Injury
Y   Seizure Disorders

Medical/Surgical:
Y   Allergies
Y   Cancer
Y   Poor Endurance
Y   Recent Surgery
Y   Diabetes
Y   Peripheral Vascular Disease
Y   Varicose Veins
Y   Hemophilia
Y   Hypertension
Y   Serious Heart Condition
Y   Stroke (CVA)

Secondary Concerns:
Y   Behavior Problems
Y   Age less than two years
Y   Age two-four years
Y   Indwelling catheter
Y   Weight Control Disorder
Y   Substance Abuse
Y   Danger to self or others
Y   Thought Control disorder
Y   Abuse of animals
Physician’s Statement:

Given the diagnosis and the medical information, this person is not medically precluded from participation in equine-assisted activities. I understand that the PATH Intl. Center will weigh the medical information given against the existing precautions and contraindications. Therefore, I refer this person to the PATH Intl center for ongoing evaluation to determine eligibility for participation.
Physician Printed Name:*
Office Name:*
License/UPIN Number:*
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Street Address

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Phone Number:*
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Physician Signature:*

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Healing Reins of Kentucky Physician Form