Health
Promotion Using Horses
Participant Application and Health History Form
General Information
Participant Name:_______________________________________________________
DOB:___/___/___
Age: ____ Height: _____ Weight:
_____ Gender: M F Ethnicity:______________
Address:
____________________________________________________________________________
Phone:__________________________
Email:_____________________________________________
Parent/Legal Guardian Name:
_________________________________________________________
Address:
____________________________________________Phone:__________________________
Employer/School/Day Hab
Site: __________________________________________________________
Affiliated
Agency/Institution:_____________________________________________________________________
Service Coordinator/Caregiver
Name:______________________________________________________________________________
Address:__________________________________________
Phone:__________________________
Referral source:_____________________________________
Phone:__________________________
How did you hear about our
program?
Emergency Contact Information
Name: ________________________________________
Relationship:__________________________
Phone:___________________
(Home) _________________(Cell)
______________________ (Work)
Address:___________________________________________________________________________
Physician’s Name/Phone:_______________________________________________________________________
Participant Name:___________________________________________
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HEALTH HISTORY Diagnosis:
____________________________________________ Date of Onset:
__________________________ Please
indicate current or past health problems, major accidents, hospitalization,
surgeries, and/or special needs: System Yes No Comment
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Participant Application
and Health History Form (con’t)
Participant Name:
_____________________________________________________ DOB: ___/___/___
MEDICATIONS
(Please list all
prescription and over the counter)
Name of Medication Dosage Frequency Time Taken
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THE
FOLLOWING WILL BE USED BY EVERYBODY RIDES STAFF TO PLAN ACTIVITIES AND THERAPY
****************************************************************************************************************************************************
Please
describe abilities, difficulties, need for assistance, equipment needs for the
following:
PHYSICAL/MOBILITY
(ambulation, transfers, bus riding, w/c use):
Please check off the following physical skills that
apply:
_____Stand on one foot _____Dresses
self _____Opens
doors/containers
_____Hop/Jump
_____Rides a bike
_____Uses utensils/tools
_____Skip
_____Plays sports
_____Manipulates fasteners
_____Weight bears on hands _____Kick a ball _____Plays on a
swing
_____Hold object _____Catch
a ball
_____Writes legibly
_____Release object
Does participant have any tactile, smell, hearing
sensitivities? (If yes, please
describe):
Does participant have any posture or balance problems?
(If yes, please describe):
Participant Application
and Health History Form (con’t)
Participant Name:
_____________________________________________________ DOB: ___/___/___
LANGUAGE
Participant communicates: _____verbally _____with assistive device _____sign language
_____picture icons
_____gestures
_____sounds
How is pain expressed?
Please check level of comprehension: _____understands simple concepts _____understands complex concepts
PSYCHOLOGICAL
(personality, likes/dislikes, fears/concerns)
SOCIAL (family
structure, leisure interests, work/school, favorite activities, companion
animals)
Please check all that apply:
_____Recognizes name _____ Knows work NO _____Understands rules ______Interacts with peers
_____Touches appropriately _____Shares items _____Appropriate conversation
COGNITIVE/EDUCATIONAL
(please check all that apply):
_____knows numbers
_____knows letters _____knows
left and right _____makes choices
_____describes feelings _____follows one-step
directions _____follows multi-step
directions
_____good problem solving _____knows prepositions
What would participant like to accomplish in equine
assisted activity and therapy?
Participant Application
and Health History Form (con’t)
RIDER SCREENING
Has participant every ridden a horse before? _____Yes
_____No
If yes, please
describe riding experience (where, how frequently, type of riding):
What adaptive equipment did rider use?
Please describe any problems related to the riding
experience:
What riding goals was rider working on?
What riding goals does rider have for this year?
Signature of client:_________________________________________________
Date: ____/____/____
Signature of guardian:
_____________________________________________ Date: ____/____/____
PLEASE
RETURN THIS APPLICATION TO:
Everybody
Rides Program Manager
c/o Wayne ARC
150
Van Buren Street
Newark
NY 14513