Date: _____________

Dear Health Care Provider:

Your Patient ______________________________________________

(Participant’s name)
is interested in participating in supervised equine activities.
In order to safely provide this service, our center requests that you complete/update the attached Medical
History and Physician’s Statement Form. 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.

Orthopedic Medical/Psychological
Atlantoaxial Instability – include neurological symptoms Allergies
Coxarthrosis Animal Abuse
Cranial Defects Cardiac Condition
Heterotopic Ossification/Myositis Ossificans Physical/Sexual/Emotional Abuse
Joint subluxation/dislocation Blood Pressure Control
Osteoporosis Dangerous to self or others
Pathologic Fractures Exacerbations of Medical
Spinal Joint Fusion/Fixation Conditions (e.g., RA, MS)
Spinal Joint Instability/Abnormalities Fire Setting
Hemophilia
Neuralogic Medical Instability
Hydrocephalus/Shunt Migraines
Seizure PVD
Spina Bifida/Chiari II Malformation/Tethered Cord/Hydromyelia Respiratory Compromise
Recent Surgeries
Other Substance Abuse
Skin Breakdown Thought Control Disorders
Age- under 4 years Weight Control Disorders
Indwelling Catheters/Medical Equipment
Medications- e.g., Photosensitivity
Poor Endurance

Participant: _________________ DOB: __________ Height: _________ Weight: ______

Address: ________________________________________________________________
Diagnosis: _____________________________________ Date of Onset: ____________
Past/Prospective Surgeries:
_______________________________________________________________
Medications: _____________________________________________________________
Seizure Type: _________________________Controlled: Y N Date of last seizure: ______
Shunt Present: Y N Date of last revision: ___________________________
Special Precautions/Needs:
_______________________________________________________________
________________________________________________________________________
______________
Mobility: Independent Ambulation Y N Assisted Ambulation Y N Wheelchair Y N
Braces/Assistive Devices: __________________________________________________

For those with Down syndrome: Neurologic Symptoms of Atlantoaxial Instability:

___Present ___Absent
Please indicate current or past special needs in the following system/areas, including surgeries. These
conditions may suggest precaution and contraindications to equine activities.

Y N Comments
Auditory
Visual
Tactile Sensation
Speech
Cardiac
Circulatory
Integument/Skin
Immunity
Pulmonary
Neurologic
Muscular
Balance
Orthopedic
Allergies
Learning Disability
Cognitive
Emotional/Psychological
Pain
Other

Given the above diagnose and medical information, this person is not medically precluded from
participation in equine-assisted activities and/or therapies. I understand the equine-assisted center
will weigh the medical information given against the existing precautions and contraindications.
Therefore, I refer this person to On Point Vaulters for ongoing evaluations to determine eligibility
for participation.

Name/Title” ____________________________MD DO NP PA Other_____________

Signature: _______________________________Date: __________________________

Address: ________________________________________________________________
Phone: __ (______) ____________________License/UPIN Number: _______________

Thank you very much for your assistance. If you have any questions or concerns
regarding this patient’s participation in equine-assisted activities, please feel free to
contact the center.

Sincerely,

Tina Silva
On Point Vaulters/Devil Dog Ranch
(804)929-2083