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.

Conditions
Orthopedic:
Spinal Fusion
Spinal Instabilities/Abnormalities
Atlantoaxial Instabilities
Scoliosis
Kyphosis
Lordosis
Hip Subluxation and Desolation
Osteoporosis
Pathologic Fractures
Coxas Arthrosis
Heterotopic Ossification
Osteogenesis Imperfecta
Cranial Deficits
Spinal Orthoses
Internal Spinal Stabilization Devices (such as Harrington Rods)

Neurological:
Hydrocephalus/shunt
Spina Bifida
Tethered Cord
Chiari II Malformation
Hydromyelia
Paralysis due to Spinal Cord Injury (above T-9)

Medical/Surgical:
Allergies to Grasses, Animals, and Dust
Cancer
Poor Endurance
Recent Surgery
Diabetes
Peripheral Vascular Disease
Varicose Veins
Hemophilia
Hypertension
Serious Heart Condition
Stroke (Cerebrovascular Accident)

Secondary Concerns:
Behavior Problems
Acute exacerbation of chronic disorder
Indwelling catheter
Weight limit 190 lbs.

Participant First Name *
Your answer
Participant Last Name *
Your answer
Address *
Your answer
Best Phone Number *
Your answer
Additional Phone Number
Your answer
Best Email *
Your answer
Additional Email
Your answer
Participant Date of Birth *
Your answer
Participant Gender *
Participant Height *
Your answer
Participant Weight *
Your answer
Participant Diagnosis *
Your answer
Date of Onset *
MM
/
DD
/
YYYY
Other Medical Conditions or Allergies
Your answer
Parent/Guardian/Caregiver Name *
Your answer
Parent/Guardian/Caregiver Place of Employment
Your answer
Participant Employer or School
Your answer
Participant Occupation
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
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 *
Your answer
Name of Insured
Your answer
Group Policy Number
Your answer
Individual Policy Number
Your answer
Medications *
Your answer
Does the participant receive any other therapies, and if so what, where, and how often? *
Your answer
Does the participant ever experience seizures? If yes: what are they like, how frequent, what are the potential triggers, are they controlled with medication, and when was the last one? *
Your answer
Please list any recent or past surgeries and their dates: *
Your answer
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? (Example: A child is asked to get a reading book, bring it back to his desk, and turn it to page 2. If he can successfully complete this, then he is following 3-step directions). *
Does the participant have any concerns regarding ability to integrate sensory information? (e.g., 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? (e.g., 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? *
Your answer
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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