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:__________________ E-mail__________________________ Alternative #:______________________

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, over-the-counter; name, dose and frequency)______________________

_________________________________________________________________________________________

_________________________________________________________________________________________

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