Request edit access
Equine Medical History Questionnaire
This form should be filled out prior to your appointment and either saved and emailed to Dr. Weidenkopf (michelleweidenkopf@gmail.com) for her review prior to your appointment or printed out and brought to your appointment. This will save time at your appointment and allow Dr. Weidenkopf to fully focus the appointment 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 and Color
Describe your concerns:
History of your horse's injuries or illnesses
History of any vaccine reactions and dates
Last farrier appointment and date
Last deworming date and product used
What does your horse eat? Include food, medications or pharmaceuticals, supplements, vitamins or minerals - the length that the horse has been on each product and why you are using it. Also have the label from each product at your appointment if possible.
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?
How many horses are in the herd?
Where is he or she in the herd? (top, middle, bottom)?
How does he or she interact with the other horses? Get picked on? Picks on others? Friendly, shy, bossy, confident, clingy, etc?
How does he or she interact with people? Friendly, shy, bossy, fearful, confident, clingy, etc?
Is he or she vocal with people or other horses? What kind of vocalizing - screaming, whinnying, nickering and when does vocalize occur?
Does your horse have a quick temper?
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?
Does your horse like to work? Does he or she learn fast? Can your horse concentrate? Does working 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 or she find touch stressful? Where on the body?
Is he or she mouthy? When? Paws the ground? When?
Does your horse tend to be hot or cold? Do you notice hot or cold body parts (ears, back, feet, etc) When?
Does your horse have a season they thrive in or do poorly in? Describe this.
Does your horse seek sun or shade at unexpected times?
Does your horse have drippy eyes? When? Is it watery or mucous? Describe
Do you see the whites of the eye or mucous membranes being red or yellow?
Does your horse have cataracts? How old was he or she when they were diagnosed?
Is there current or was there previous episodes of uveitis, moon blindness or allergy symptoms in the eye? Describe.
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 or she itchy? Rub their face on front legs? Where and when?
If he or she gets a cut or scrap does it heal at a normal rate? If not, describe.
Does your horse's hair coat fade? Is it dull or healthy looking?
When was your horse's last dental exam? Was dental work done?
Good teeth or a history of problems?
Trouble chewing? Dropping feed?
Trouble with the bit? Mouth or tongue activity while riding?
Bad breath? Excessive salivating or a dry mouth? describe.
Is there 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?
Is your horse's appetite good? Describe.
What does the manure look like? (dry, loose, wet at the beginning or end of defication)? Are there excessively big or small piles? If it is variable, describe. Is it smelly?
Does he pass gas? Is it smelly or loud?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service