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Equine Intake Form
Hello and welcome to our intake form for horse consults. Please read each question carefully and answer to your best ability. If you have any questions, we can be reached at get@apleasantdog.com or 616-264-2532 during regular business hours. Thank you for trusting us with your equine friend!
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Who referred you to A Pleasant Horse?
Your answer
Today's Date
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Your Contact Information
Owner's Name
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Your answer
Phone Number
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Your answer
Address
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Your answer
Email
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Your answer
Your Horse's Information
Horse’s Name
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Your answer
Breed
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Your answer
Age
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Your answer
Sex
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Your answer
Color
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Your answer
Main Behavior Problem
Please describe the main behavior problem?
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Your answer
When did the problem begin?
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Your answer
The main problem occurs when? (check all that apply)
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When the horse is alone.
In the presence of other horses.
In the presence of the owner.
In the absence of the owner (other people present).
In the stall.
In the pasture.
At competitions or group events.
Under saddle or at work.
Prior to feeding.
During feeding.
After feeding.
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How often does this behavior occur?
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Daily
Weekly
Monthly
Has there been a change in the frequency, intensity of appearance of the problem?
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Your answer
What has been done so far to correct the problem?
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Your answer
What has been the horse's response to the correction?
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Your answer
Has anything changed in this horse’s environment prior to the appearance of the problem (new stall, new barn, new feed, new horses, new saddle, etc.?)
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Your answer
Horse's Environment
Type of housing (stall, pasture, run-out shed)?
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Your answer
Diet: Grain type? Hay type?
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Your answer
What supplements is this horse on
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Your answer
Exercise (hrs. per wk. ridden/ hrs. per wk. in paddock)?
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Your answer
Type of bit used?
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Your answer
Type of saddle used?
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Your answer
Other horses in environment and relations between horses (friendly, aggressive, neutral)?
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Your answer
Other animals in environment?
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Your answer
Primary caretaker of this horse.
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Your answer
Primary trainer of this horse?
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Your answer
Do you compete with this horse? What discipline?
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Your answer
Early History
Age at weaning?
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Your answer
Age when obtained by present owner?
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Your answer
Were there previous owners?
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Your answer
Do related horses have similar problems?
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Your answer
Education
Age at halter breaking?
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Your answer
Method of training to saddle or harness, age when training began?
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Your answer
Other types of training methods? (driving, jumping, dressage, games, trail riding, cutting)
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Your answer
Other Behavior Problems
Please Describe
Shying, how often and at what?
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Your answer
Any other phobias?
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Your answer
Head shy?
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Your answer
Resentful of grooming/ handling (brushing, hoof picking clipping, etc.)?
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Your answer
Difficult to handle when hoof trimming or shoeing?
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Your answer
Difficult to load or trailer?
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Your answer
Aggression towards humans or animals (dogs, cows, etc.) including threatens, strikes, bites, kicks, chases)?Difficult to load or trailer?
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Your answer
Aggression toward other horses (threatens, strikes, bites, kicks, chases)?
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Your answer
Misbehavior Under Saddle (check all that apply)
Moves while rider mounts
Backs in harness
Bucks
Rears
Wrings tail
Sensitive to saddling, girth tightening
Wants to lead or will only follow other horses
Runs away when approached
Slow to leave and quick to return to barn
Hard to get or keep on right or left lead
Barn Vices (
Check all that apply)
Aggressive in stall (pins ears, threatens)
Cribs
Chews wood
Food aggressive
Kicks stall
Paws
Paces
Sexual behavior: excessive, inadequate, abnormal? Describe.
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Your answer
Maternal behavior: excessive, inadequate, abnormal? Describe.
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Your answer
Physical History
Current medical problems?
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Your answer
Past medical problems (surgical or medical)?
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Your answer
Medication history?
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Your answer
Results of diagnostic tests (radiographs, blood work)?
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Your answer
How often are the teeth floated? When was the last float?
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Your answer
The information you have provided will be used during your consultation will be used to develop an assessment and training/management plan. All information will be held in confidence but will be shared with your veterinarian and their team.
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I Understand
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