Physician's Statement
Dear Health Care Provider:
Your patient is interested in participating in the Spirit Open Equestrian Program. In order to safely provide this service,
we need your help. Please answer the questions below and sign this form to support our processes.
Thank you for your time
Spirit Team
www.spiritequestrian.org
* Required
This form MUST be signed by a licensed physician
Name of patient/participant of Equine Assisted Activity / Equine Assisted Psychotherapy/ Therapeutic Riding or Equine Assisted Learning
*
Your answer
Primary condition indicated for Equine Assisted Activities
*
Your answer
Secondary and other conditions to be considered
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Weight
*
Your answer
Height
*
Your answer
Possible contraindications
Your patient is interested in participating in supervised equestrian activities. In order to safely provide this service, our center requests that you complete/update this form. Please note that the following conditions may suggest precautions and contraindications to therapeutic horseback riding. Therefore, when completing this form, please note whether these conditions are present, and to what degree.
*
Atlantoaxial instability
Allergies
Coxaarthrosis
Cranial Deficits
Physical/sexual/emotional abuse
Heterotopic Ossification/Myositis
Blood pressure control
Joint subluxation/dislocation. Dangerous to self or others
Osteoporosis exacerbations of medical conditions
Pathologic fractures fire settings
Spinal fusion/fixation
Heart conditions
spinal instability/abnormalities
Hemophilia
Migraines
Hydrocephalus/shunt PVD
Seizure respiratory compromise
Spina bifida/chiari II malformation
Tethered cord
Recent surgeries
Hydromyelia substance abuse
Thought control disorders
Weight control disorder
Age - usually under 4 years
Indwelling catheters
Medications, i.e. photosensitivity
Poor endurance
Skin breakdown
Anger management
None
Comments
Your answer
Date of Onset
MM
/
DD
/
YYYY
Past/prospective surgeries
*
Your answer
Medications
*
Your answer
Seizure type
*
Your answer
Controlled?
*
Yes
No
N/A
Date of last seizure
MM
/
DD
/
YYYY
Shunt present?
*
Yes
No
Date of last revision
MM
/
DD
/
YYYY
Special precautions, diets/needs
*
Your answer
Can s/he participate in mounted activities (Therapeutic Riding)?
*
Yes
No
Required
May participate except for:
*
Your answer
Mobility
Independent Ambulation?
*
Yes
No
N/A
Assisted ambulation?
*
Yes
No
N/A
Wheelchair?
Yes
No
Clear selection
Braces/assistive devices
If patient has Down syndrome, can you provide x-rays for Neurological symptoms of atlanto-axial instability?
*
Yes
No
N/A
Tetanus shot?
Yes
No
Clear selection
Date
MM
/
DD
/
YYYY
Please indicate current or past difficulties in the following systems/areas, including surgeries
Auditory
Your answer
Visual
Your answer
Tactile sensation
Your answer
Speech
Your answer
Cardiac
Your answer
Circulatory
Your answer
Skin
Your answer
Immunity
Your answer
Pulmonary
Your answer
Neurological
Your answer
Muscular
Your answer
Balance
Your answer
Orthopedic
Your answer
Allergies
Your answer
Learning disability
Your answer
Cognitive
Your answer
Emotional/psychological
Your answer
Pain
Your answer
Other
Your answer
To my knowledge, there is no reason why s/he cannot participate in supervised equestrian activities
*
Yes
No
Required
Expected benefits from Equine Assisted Activities
*
Your answer
Signature - By typing your name here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. However I understand that the medical information above will be taken against the existing precautions and contraindications. I concur with a referral of the patient to a licensed/credentialed health professional (e.g., PT, OT, Speech, Psychologist, etc.) in the implementations of an effective equestrian program.
*
Your answer
Name/Title
*
Your answer
MD, DO, other
*
Your answer
Date
*
MM
/
DD
/
YYYY
License/UPIN number
*
Your answer
Thank you!
Thank you very much for your assistance. If you have any questions or concerns regarding this patient's participation in therapeutic equine activities, please feel free to contact me as indicated below.
This e-mail form is intended only for the use of the individual or entity; it is confidential and disclosure is prohibited. If you have received this e-mail in error, please notify the sender immediately either by e-mail or phone and delete this e-mail from your computer.
Sincerely,
Davorka Suvak
Spirit Open Equestrian Program, Inc.
Executive and Program Director
703 600 9667
spiritoep@spiritequestrian.org
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