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Equine Medical History Questionnaire
This form should be filled out prior to your appointment and either saved and emailed to Dr. Weidenkopf (drmichelle@holisticveterinaryoptions.com) for her review prior to your appointment or printed out and brought to your appointment. This will save time during your appointment and allow Dr. Weidenkopf to fully focus on the patient. It is also important to have your horse clean and dry for the appointment. Treatment may not be possible if your horse is too dirty or wet.
Owner name/email
Owner address
Owner phone number
Patient name
Patient age, gender, color and breed (if known)
Describe your concerns. What do you hope to help your horse with?
What treatments have been used to address this condition? What was the response to treatment?
History of your horse's injuries or illnesses. If the history is complicated, please briefly summarize here and make your medical records available to share with me.
Is your horse vaccinated? How frequently is it done? Which vaccines are used? Have there been any vaccination reactions? If so please list date of reaction, vaccine type and describe the reaction.
Last farrier appointment and date? Who is your farrier? Does your horse wear shoes and for what reason? How frequently does the farrier trim/shoe your horse? Do the hooves grow at a normal rate?
Last deworming date and product used. How often do you deworm? Has your horse had fecal egg counts? If so, is he/she a heavy shedder?
Is your horse exposed to pesticides/herbicides? (Common exposure would be from fly spray or chemicals sprayed in the barn to control bug populations. Also feed containing Round-up ready ingredients or crops that are sprayed with Round-up pre-harvest. They include alfalfa, corn, soybeans, wheat, oats and other legumes. These ingredient sources can be found in all non-organic horse grain.)
When was your horse's last dental exam? Was dental work done?
Good teeth or a history of problems? Trouble chewing or dropping feed?
Trouble with the bit? Mouth or tongue activity while riding?
Bad breath? Excessive salivating or a dry mouth? describe.
What does your horse eat? Include food, treats, medications/pharmaceuticals, supplements, vitamins/minerals - the length that the horse has been on each product and why you are using it. Please have the label from each product at your appointment, if possible.
Is your horse's appetite good? Is it easy to keep your horse at a healthy weight? If not, describe.
Does your horse tend to be hot or cold? Do you notice hot or cold body parts (ears, back, around hooves, etc) When? Does your horse seek sun or shade at unexpected times?
Does your horse have a season they thrive in or do poorly in? Describe this.
Do the whites of your horse's eyes or it's mucous membranes look red or yellow?
Does your horse have cataracts? How old was he or she when they were diagnosed? Does your horse have drippy eyes? When? Is it watery or mucous? What color is the liquid? Describe.
Is there current or was there previous episodes of uveitis, moon blindness or allergy symptoms in the eye? Was the problem in one or both eyes? Describe.
Does you horse cough? If so, when and how frequently? If yes, is it a soft or forceful cough? Wet or dry? Does the cough get worse with exercise or certain weather or environments?
Does your horse tend toward dryness or oiliness? Looking at skin, hooves, hair, mane and tail.
Has your horse had hives? What was the possible cause? Does your horse have bug bite sensitivity?
Is he/she itchy? Rub their face on front legs? Where and when?
If he or she gets a cut or scrape does it heal at a normal rate? If not, describe.
Does your horse have any scars, swelling or other leg issues? Describe.
Do the legs stock up (swelling around hoof or cannon bone)? Is it all legs? If it is not all the time, when does it happen? Is it hot and painful?
Does your horse's hair coat fade? Is it dull or healthy looking? Does the hair fully shed out in the spring? Does the hair coat appear normal in the winter and the summer? If not, describe.
What does the manure look like? (dry, loose, wet at the beginning or end of defecation)? Are there excessively big or small piles? If it varies describe each type. Is it smelly?
Does he pass gas? Is it smelly or loud? Does it occur during exercise or when just standing around?
How long has your horse been with you? Describe what you know about its life before coming to you.
Does your horse travel well? How often does he or she travel? Is it for shows, trail riding, camping, clinics, moving to new homes, etc?
Describe housing and the amount if time in a stall and outdoors? Where is he/she happiest?
How many horses are in the herd? Where is your horse in the herd? (top, middle, bottom)? How does he/she interact with the other horses? Get picked on? Pick on others? Friendly, shy, bossy, confident, clingy, etc? Is he/she anxious when removed from the herd?
How does he or she interact with people? Friendly, shy, bossy, fearful, confident, clingy, etc? Does your horse have a quick temper with people or other animals?
Is he or she vocal with people or other horses? What kind of vocalizing - screaming, whinnying, nickering and when does vocalization occur?
Do you see you horse's energy level as normal, high or low?
Do you see your horse playing? When? During work, in the pasture, in the stall? Playing with other horses, other species or objects? Playing by running around?
Is your horse at work? If not, why? If your are working your horse what type of work are you doing? What is the frequency and duration of work?
Does your horse like to work? Does he or she learn fast? Can your horse concentrate? Does work make your horse anxious?
Describe anything that makes your horse anxious and when and where it occurs? List fears, phobias, noises, sights, situations. Examples: trailering, cows, loud noises, being in a stall, etc.
Does he/she find human touch stressful? Where on the body?
Is he/she mouthy? When? Paws the ground? When?
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