Hooves to Heal NFP 20604 Collins Rd. Marengo, IL 60152
Particpant's Application and Health History
GENERAL INFORMATION
Participant:________________________________________________________________________________
DOB:_____________ Age:__________ Height:__________Weight:__________ Gender: M F
Address:__________________________________________________________________________________
Phone:__________________
Employer/School:__________________________________________________________________________
Address:_________________________________________________________________________________
Phone:___________________________________________________________________________________
Parent/Legal Guardian:______________________________________________________________________
Address (If different from above)_______________________________________________________________
Phone:__________________________________________Alternative #:______________________________
Referral Source:____________________________________________________________________________
How did you hear about the program?__________________________________________________________
HEALTH HISTORY
Diagnosis___________________________________________Date of Onset:__________________________
Please indicate current or past special needs in the following areas:
|
Circle |
Comments |
|
Allergies |
Y |
N |
|
Behavioral |
Y |
N |
|
Bone/Joint |
Y |
N |
|
Breathing |
Y |
N |
|
Circulation |
Y |
N |
|
Communication |
Y |
N |
|
Digestion |
Y |
N |
|
Elimination |
Y |
N |
|
Emotional/Mental Health |
Y |
N |
|
Hearing |
Y |
N |
|
Heart |
Y |
N |
|
pain |
Y |
N |
|
Muscular |
Y |
N |
|
Sensation |
Y |
N |
|
Thinking/Cognition |
Y |
N |
|
Vision |
Y |
N |
|
Sudden movement/ |
Y |
N |
|
Outbursts |
|
|
|
Particpant's Application and Health History (cont.)
MEDICATIONS (include prescription,
_________________________________________________________________________________________
_________________________________________________________________________________________
Describe your abilities;difficulties in the following areas (including assistance required or equipment needed): PHYSICAL FUNCTION (i.e., Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PSYCHO/SOCIAL FUNCTION (i.e., Work/school including grade completed, leisure interests, relationship- family structure, support systems, companion animals, fears/concerns, etc)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
GOALS (i.e., Why are you applying for participation? What would yo ulike to accomplish?)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Signature:__________________________________________________________Date:__________________
Participant, Parent or Legal Guardian Signed in the presence of center staff