Rider physiotherapy assessment mechanical horse

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Please complete all sections of this form 48 hours prior to your session.

All medical information provided will be used for your physiotherapy assessment only and will be stored securely.

For your session please wear clean riding boots and jodpurs/tights with a baselayer type top so we can assess your posture. Bring riding gloves if you normally use them.

Maximum weight limit 16 stone.

Email *

Full Name *

Date of Birth *

YYYY

Mobile phone number *

Date of your session *

YYYY

First line of address and postcode *

Medical conditions (select all that apply) *

Night pain

Night sweats

Unexplained weight loss

Pins and needles/numbness in arms or legs

Arm or leg weakness

Neck pain

Back pain

Shoulder pain

Hip pain

Knee pain

Ankle pain

Problems with coordination or balance

High blood pressure

Diabetes

Epilepsy

Asthma

Significant previous injuries or operations

None of the above

Other:

Required

Please provide futher information on medical history above if appropriate

Please describe any physical problems you currently have and/or what you would like to get out of your session *

GDPR- i consent to my data being used by Pegasus Physiotherapy only, for future marketing and promotions from Pegasus *

Yes

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