Telephone: (903)640-9106

Fax: (903)583-9389

Name _____________________________________________________

Date _____________________________________________________

Current Medications ____________________________________________

_____________________________________________________________

In order to safely provide services to all participants in a safe manner, HHH requests that you circle any condition below that relates to you.

Orthopedic Other

Coxa Anthrosis Indwelling Catheters

Crianial Deficits Medications – i.e. photosensitivity

Heterotopic Ossification/Myositis Ossificans Poor Endurance

Joint sublization/dislocation Skin Breakdown

Osteoporosis

Pathologic Fractures

Spinal Fusion/Fixation

Spinal Instability/Abnormalities

Hydrocephalus/Shunt

Seizure Disorders

Spina Bifida/Chiari III malformation

Tethered Cord/Hydomyelia

Asthma

Allergies

Bi-Polar

Blood Pressure Control

Diabetic

Heart Conditions

Hemophilia

Migraines

Peripheral Vascular Disease

Respiratory Compromise

Recent Surgeries

Substance Abuse

Thought Control Disorders

Weight Control Disorders