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.

Orthopedic:
Fusion
Instabilities/Abnormalities, including Atlantoaxial Instability (common with Down Syndrome, JRA)
Scoliosis/Kyphosis/Lordosis
Spinal Orthoses
Internal Spinal Stabilization Devices (such as Harrington Rods)
Hip Subluxation and Dislocation
Coxarthrosis
Pathologic Fractures
Heterotopic Ossification
Osteogenesis Imperfecta
Osteoporosis
Cranial Deficits
Joint instabilities

Neurological:
Hydrocephalus/shunt
Spina Bifida
Tethered Cord
Chiari II Malformation
Hydromyelia
Paralysis due to Spinal Cord Injury (above T-6)
Seizure disorder or history of seizures

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)
Acute exacerbation of chronic disorder (Rheumatoid Arthritis, Herniated Disk, Multiple Sclerosis, etc)
Open wound over weight bearing surface
Indwelling urethral catheter

Other:
Mental/behavioral disorders that would be unsafe (fire setting, animal abuse, violent behavior, etc)
Weight over 190 lbs.
Participant First Name *
Participant Last Name *
Address *
City, State & Zip Code *
Best Phone Number *
Additional Phone Number
Best Email *
Additional Email
Participant Date of Birth *
Participant Gender *
Participant Height *
Participant Weight *
Participant Diagnosis *
Date of Onset *
MM
/
DD
/
YYYY
Other Medical Conditions or Allergies
Parent/Guardian/Caregiver Name *
Parent/Guardian/Caregiver Place of Employment
Participant Employer or School
Participant Occupation
Emergency Contact Name *
Emergency Contact Number *
How did you learn about Forward Stride? *
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 *
Physician's Number *
Physician's Fax Number *
Health Insurance Provider *
Name of Insured
Group Policy Number
Individual Policy Number
Medications *
Does the participant receive any other therapies, and if so what, where, and how often? *
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? *
Please list any recent or past surgeries and their dates: *
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? *
Any history of hip subluxations or dislocations? Has the participant had any hip x-rays? If yes, when and what was the result? *
Can the participant hold their head upright and in mid-line? *
Can the participant sit independently? *
Does the participant have any mobility issues? *
Can the participant walk independently? *
If the participant uses a wheelchair can they transfer themselves independently?
Clear selection
What adaptive equipment does the participant use? (ex: orthotics, wheelchair, walker, crutch, communication devices) *
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) *
How does the participant communicate? *
How does the participant best learn? (e.g., mainly by seeing, doing, listening) *
What short-term goals would you like to accomplish by participating in our therapy program? *
What long-term goals would you like to accomplish by participating in our therapy program? *
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?
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