Yearly Medical Update

Date *

Dear Health Care Provider

Your Patient *

Has been participating in supervised mounted equine activities at Thorncroft Equestrian Center and is due for an update of his/her medical status. Please review the previous medical history and provide an update of the information in the space below. Address occurrences over the past year including surgeries, illnesses, and hospitalizations, changes in medications, treatment, weight or behavior. Please indicate current height/weight. If this person has Down syndrome or any other condition that predisposes him/her to Atlantoaxial Instability, please include results of his/her neurologic exam.

Diagnosis *

Height *

Weight *

Update Status (For individuals with Down Syndrome, please state any changes in AAI) *

Given the above diagnosis and medical information, this rider is eligible to continue in mounted equineassisted activities and/or therapies. I understand that Thorncroft Equestrian Center will weigh the medical information given against the existing precautions and contraindications. I refer this rider to Thorncroft Equestrian Center for ongoing evaluation to determine continued eligibility for participation.

Print Name/Title *

MD DO NP PA Other *

Signature *

"By filling out your full name here, you are e-signing this document"

Date *

Address *

Phone *

License/UPIN Number *