Physical, Occupational or Speech and Language Therapy Registration


PRECAUTIONS or CONTRAINDICATIONS
The following conditions, if present, may represent PRECAUTIONS or CONTRAINDICATIONS to Rehabilitation Services. Therefore, when completing this form, it is important to note whether these conditions are present, and to what degree.

Participant First Name
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Participant Last Name
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Address
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Best Phone Number
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Additional Phone Number
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Best Email
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Additional Email
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Participant Date of Birth
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Participant Gender
Participant Height
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Participant Weight
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Participant Diagnosis
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Date of Onset
MM
/
DD
/
YYYY
Other Medical Conditions or Allergies
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Parent/Guardian/Caregiver Name
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Parent/Guardian/Caregiver Place of Employment
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Participant Employer or School
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Participant Occupation
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Emergency Contact Name
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Emergency Contact Number
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How did you learn about Forward Stride
Your answer
Medical Information
We want to make sure that this type of therapy (using the movement of an equine as one of the treatment tools) is an appropriate treatment option for the participant. Please complete the following questions so we can better get to know them:
Physician's Name
Your answer
Physician's Number
Your answer
Health Insurance Provider
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Name of Insured
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Group Policy Number
Your answer
Individual Policy Number
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Medications
Your answer
Does the participant receive any other therapies, and if so what, where, and how often? (ex: PT 1/x per week at Emanuel, school based OT and SLP 2x/wk, aquatic therapy at Providence).
Your answer
Does the participant ever experience seizures? If yes, what are they like, how frequent, what are the potential triggers and are they controlled with medication?
Your answer
Please list any recent or past surgeries and their dates:
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Does the participant have any psychological, behavioral or social challenges such as anxiety, depression, aggression or fear that may impact their experience on a horse?
Your answer
Any history of hip subluxations or dislocations? Has the participant had any hip x-rays? If yes, when and what was the result?
Your answer
Can the participant hold their head upright and in mid-line?
Can the participant sit independently?
Does the participant have any mobility issues?
Your answer
Can the participant walk independently?
If the participant uses a wheelchair can they transfer themselves independently?
What adaptive equipment does the participant use? (ex: orthotics, wheelchair, walker, crutch, communication devices)
Your answer
Does the participant follow directions well? 1 step, 2 step, 3 step, complex (Example: when a child is asked to get a reading book bring it back to his desk and turn it to page 2 he is following 3-step directions).
Does the participant have any concerns regarding ability to integrate sensory information? (ex; sensitive to touch, light or sound, seeks movement and like to touch people and objects, loves or hates swings or having their head inverted, doesn’t like certain textures or tastes)
Your answer
How does the participant communicate?
How does the participant best learn? (ex; mainly by seeing, doing, listening)
Your answer
What short term goals would you like to accomplish by participating in our therapy program?
Your answer
What long term goals would you like to accomplish by participating in our therapy program?
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Please check all areas of concern.
Required
Please number your preference for therapy (1 through 3)
First
Second
Third
Physical Therapy
Occupational Therapy
Speech & Language Therapy
Is there any other information that you feel would be important for us to know so that we can provide the best service to this client?
Your answer
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