Rider's Health History

Rider's Health History

Valley Riding, Inc.
North American Riding for the Handicapped Association
Valley Riding, Inc. 19901 Puritas Ave. Cleveland, OH 44135 216-267-2525 216-267-9743 (fax)
Participant Name*
Participant Date of Birth (DOB)*

MonthDayYear
Date
Age*
Height*
Weight*
Gender*

MaleFemale
Address*
Phone*
Email*
example@example.com
Alternate Phone #
Employer or School*
Employer or School Address*
Employer or School Phone*
Parent/Legal Guardian Name*
Parent/Guardian Address (if different from above)*
Parent/Guardian Phone*
Referral Source
Referral Source Phone
How did you hear about the program*
HEALTH HISTORY
Diagnosis*
Date of Onset*

MonthDayYear
Date
Please indicate current or past special needs in the following areas:*

VisionHearingSensationCommunicationHeartBreathingDigestionEliminationCirculationEmotional/Mental HealthBehavioralPainBone/JointMuscularThinking/CognitionAllergies
Please provide comments to any special needs noted*
MEDICATIONS (include prescription, over the counter; name dose and frequency)*
Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):
PHYSICAL FUNCTION (i.e. Mobility skills such as transfers walking wheelchair use driving bus riding)*
PHYSICAL SOCIAL FUNCTION (i.e. Work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)*
GOALS (i.e. Why are you applying for participation? What would you like to accomplish?)*
Signature*

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Date*

MonthDayYear
Date
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Rider's Health History

HEALTH HISTORY