| Document Date: 2014-09-11 15:41:00
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City Orlando / / Company Freedom Ride Inc. / / / MedicalCondition Spinal Cord Injury Behavior problems Seizure / catheter Spina Bifida Integumentary/Skin Tethered Cord PARTICIPANTS WITH DOWN SYNDROME / Malformation Secondary Concerns Hydrocephalus / Dislocation Hypertension Internal Spinal Stabilization Devices Peripheral Vascular Disease Kyphosis Poor Endurance Lordosis Recent Surgery Osteogenesis Imperfecta Serious Heart Condition Osteoporosis Stroke / Last Seizure / Cerebrovascular Accident / years Paralysis / Any contagious diseases / Down Syndrome / / MedicalTreatment catheter / / / Position Physician / office MEDICAL HISTORY AND PHYSICIAN / PHYSICIAN INFORMATION The / / ProvinceOrState Florida / / Technology x-ray / / URL www.freedomride.com / /
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Freedom Ride Inc 1905 Lee Road, Orlando, FL[removed]Phone: [removed]Fax: [removed]www.freedomride.com / Please return originally completed forms to the office MEDICAL HISTORY AND PHYSICIAN’S RELEASE – MUST BE