Medical Consent Form - Tauranga Riding For Disabled Page 2
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3The following conditions, if present, may represent precautions or contraindications to therapeutic horseback riding.
Therefore when completing this Medical Consent Form, please note indicate below whether these conditions are present,
and to what degree:
Orthopaedic
Details
Spinal Fusion
No
Yes
___________________________________________________
Spinal Instabilities / Abnormalities
No
Yes
___________________________________________________
Atlantoaxial Instabilities
No
Yes
___________________________________________________
Scoliosis
No
Yes
___________________________________________________
Kyphosis
No
Yes
___________________________________________________
Lordosis
No
Yes
___________________________________________________
Hip Subluxation & Dislocation
No
Yes
___________________________________________________
Osteoporosis
No
Yes
___________________________________________________
Pathologic Fractures
No
Yes
___________________________________________________
Coxas Arthrosis
No
Yes
___________________________________________________
Heterotopic Ossification
No
Yes
___________________________________________________
Osteogenesis Imperfecta
No
Yes
___________________________________________________
Cranial Deficits
No
Yes
___________________________________________________
Spinal Orthoses
No
Yes
___________________________________________________
Internal Spinal Stabilisation Devices
No
Yes
___________________________________________________
Medical /Surgical
Details
Allergies
No
Yes
___________________________________________________
Cancer
No
Yes
___________________________________________________
Poor Endurance
No
Yes
___________________________________________________
Recent surgery
No
Yes
___________________________________________________
Diabetes
No
Yes
___________________________________________________
Peripheral Vascular Disease
No
Yes
___________________________________________________
Varicose Veins
No
Yes
___________________________________________________
Haemophilia
No
Yes
___________________________________________________
Hypertension
No
Yes
___________________________________________________
Serious Heart Condition
No
Yes
___________________________________________________
Stroke
No
Yes
___________________________________________________
Neurologic
Details
Hydrocephalus / shunt
No
Yes
___________________________________________________
Spina Bifida
No
Yes
___________________________________________________
Tethered Cord
No
Yes
___________________________________________________
Chiari II malformation
No
Yes
___________________________________________________
Hydromyelia
No
Yes
___________________________________________________
Paralysis due to spinal cord injury
No
Yes
___________________________________________________
Seizure / Epilepsy Disorders
No
Yes
___________________________________________________
Secondary Concerns
Details
Behaviour problems
No
Yes
___________________________________________________
Acute exacerbation of chronic disorder
No
Yes
___________________________________________________
Indwelling catheter
No
Yes
___________________________________________________
Gastrostomy Tube
No
Yes
___________________________________________________
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