Intake Form: Equine Physiotherapy Clients

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THANK YOU FOR CHOOSING ALL IS ONE WELLNESS ARTS FOR YOUR ANIMAL COMPANION'S NEEDS. THESE FORMS ARE QUITE COMPREHENSIVE TO ALLOW US TO PROVIDE THE BEST POSSIBLE CARE.

I am a professionally licensed and insured practitioner. I adhere to the highest ethical standards of practice and compliance with national and state laws regarding my profession. Please note that my care is not a substitute for appropriate veterinary care.

EQUINE PHYSIOTHERAPY CLIENTS: PLEASE FILL OUT THE FORM BELOW.

(ANIMAL REIKI CLIENTS: RETURN TO WEBSITE TO FILL OUT THE ANIMAL REIKI CLIENT FORM.)

Date *

YYYY

Name (First & Last) *

Email Address *

Phone Number *

Horse Name *

Breed and Approximate Height *

Sex *

Mare

Gelding

Stallion

Year Foaled *

How long have you owned or cared for this horse? *

How do you use your horse? (Pleasure, pet, roping, dressage, etc.) *

Primary reason for seeking bodywork on your horse? *

Previous pertinent history: showing, work, neglect, abuse, etc. *

In the last 3 months, describe average work: # of days worked, level of intensity *

Do you work with a riding coach? If so, how many times/month and how long working with that person? *

Type of saddle used?

Have you had any saddle fit issues, or had your saddle fit checked?

How long has horse been worked in this saddle?

Please describe bridling/bitting used most of the time: snaffle, shank, etc.

Hoof protection (choose one): *

Barefoot

Plain front shoes

All feet shod w/plain shoes

Special shoes, pads, clips, etc.

Name of your hoof care practitioner/farrier, and how long they have been working on your horse.

How often are feet trimmed/shoed?

Hoof issues? Please describe any previous or ongoing hoof issues, such as thrush, white line disease, laminitis, navicular syndrome, thin soles, frequent abcesses, frequent throwing shoes, how often feet are trimmed/shod

Is your horse current on vaccines? *

Yes

Approximate date of last deworming? *

Describe current feed program. Please include amounts of grain, cubes/hay, supplements and how much per/day *

Does your horse typically have a lot of gas, particularly loud?

Yes

Clear selection

Does your horse have unusually foul smelling, or loose fecal matter on a regular basis?

Has your horse ever been diagnosed or suspected of having gastric ulcers or hind gut issues? *

Yes

Approximate date of last equine dental exam *

Please describe how your horse lives daily- # hrs in a stall, pasture, etc. *

Please check boxes if your horse is sensitive to being: *

Girthed/cinched up

Groomed over back

Touched near the sheath or udders

Grooming over the ribs/barrel

Touchy around the poll/ears

None of the above

Required

Does your horse pull back when tied? *

Yes

Sometimes

Do you have any radiographs (x-rays) of your horse? If so, please describe. *

Please describe any lameness issues, past or present. *

Please let me know if your horse has ever foundered, bowed a tendon, any fractures, injured tendons or ligaments, had stifle or hock issues, if you get your horse injected with steroids for any reason, etc.

Has your horse ever been diagnosed or treated for neurological issues, such as Wobblers, shivers, EPM, stringhalt?

Yes

Clear selection

Has your horse ever flipped over or fallen down?

Yes

Clear selection

Please describe any accident or illness not already covered that was serious enough to make you not ride the horse for even a day.

Is there anything else you would like to tell me about your horse?

Submit

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