Rider's Medical History & Physician's Statement

Please have your physician fill out and submit the form below or Rider’s Medical History and Physician's Statement - 2017.pdf and send it to P.O. Box 906 La Crosse, WI 54602.

HorseSense for Special Riders is a therapeutic riding program designed to benefit the riders physically, socially, and emotionally. Safety equipment and specially trained horses and volunteers are used in order to assure the fullest possible protection and greatest personal benefit from the program. Each rider is required to furnish the following medical information before being accepted as a rider.

For persons with Down Syndrome
YesNo
Auditory
Visual
Speech
Cardiac
Circulatory
Pulmonary
Neurological
Muscular
Orthopedic
Allergies
Learning Disability
Mental Impairment
Psychological Impairment
Other
If you answered "Yes" to any of the areas above, please explain more here.
YesNo
lndependent Ambulation
Crutches
Braces
Wheelchair

To my knowledge, there is no reason why this person cannot participate in supervised equestrian activities. However, I understand that the therapeutic riding center will weigh the medical information above against the existing precautions and contraindications. I concur with a review of this person's abilities/limitations by a licensed/credentialed professional (e.g. PT, OT, Speech, Psychologist, etc.) in the implementing of an effective equestrian program.

The following conditions, if present, may represent precautions or contraindications to therapeutic horseback riding. Therefore when completing this form, please note whether these conditions are present, and to what degree.

Orthopedic

Spinal Fusion
Spinal Instabilities I Abnormalities
Atlantoaxial
Scoliosis
Kyphosis
Lordosis
Hip Subluxation & Dislocation
Osteoporosis
Pathologic Fractures
Coxas Arthrosis
Heterotopic Ossification
Osteogenesis Imperfecta
Cranial Deficits
Spinal Orthoses

Medical/Surgical

Allergies
Cancer
Poor Endurance
Recent Surgery
Diabetes
Peripheral Vascular Disease Varicose Veins Hemophilia Hypertension
Serious Heart Condition Stroke (Cerebrovascular Accident)

Neurologic

Hydrocephalus I Shunt
Spina Bifida
Tethered Cord
Chiari II Malformation
Hydromyelia
Paralysis due to Spinal Cord injury
Seizure Disorders

Secondary Concerns

Behavior problems
Age under two years
Age two - four years
Acute exacerbation of chronic disorder
Indwelling catheter

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