Dear Health Care Provider,
Your Patient: *
is in need of authorization to begin or continue participating in equine activities at Kids & Horses. Please review their previous medical history and provide medical information in the space below. Address occurrences including surgeries, illnesses, hospitalization and changes in medications, treatments, weight or behavior. Please indicate height and weight. For your reference, a list of potential precautions/contraindications is attached.
Diagnosis: *
Height: *
Weight: *
Update Status: *
For those with Down Syndrome: An Atlantoaxial x-ray and annual exam to exclude Atlantoaxial instability for clients with Down Syndrome over the age of 3.
Date of X-Ray:
Given the above diagnosis and medical information, this person is not medically precluded from participation in supervised equestrian activities. I understand that Kids & Horses will weigh the medical information indicated above against any existing precautions and/or contraindications before allowing this person to participate in adaptive riding or physical therapy, occupational therapy or speech-language pathology utilizing equine movement as a treatment strategy. Therefore, I refer this person to Kids & Horses for ongoing evaluation to determine eligibility for participation.
Name/Title: *
Item #13 *
Signature: *
Date: *
Address: *
Phone: *
License/UPIN Number: *
Precautions/Contraindications Please note that the following conditions may suggest precautions and contraindications to horseback riding. Therefore, when completing this form, please note whether these conditions are present and to what degree.  
Orthopedic *
 Atlantoaxial Instability- include neurologic sympto
 Coxa Arthrosis
 Cranial Defects
 Heterotopic Ossification/ Myositis Ossificans
 Joint subluxation/dislocation
 Pathological Fractures
 Spinal Joint Instabilities/Abnormalities
 None of the Above
Neurologic: *
 Hydrocephalus/ shunt
 Sensory Deficit
 Spina Bifida/ Chiari II Malformation/ Tethered Cord/ Hydromyelia
 None of the Above
Medical/Psychological *
 Animal Abuse
 Cardiac Condition
 Physical/Sexual/Emotional Abuse
 Blood Pressure Control
 Dangerous to self or others
 Exacerbations of medical conditions (i.e. RA, MS)
 Fire Settings
 Medical Instability
 Respiratory Compromise
 Recent Surgeries
 Substance Abuse
 Thought Control Disorders
 Weight Control Disorders
 None of the Above
Other: *
 Indwelling Catheters/Medical Equipment
 Poor Endurance
 Skin Breakdown
 None of the Above
Comments: *