Intake Form: Equine Physiotherapy Clients
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 *
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Name (First & Last) *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Horse Name *
Your answer
Breed and Approximate Height *
Your answer
Sex *
Year Foaled *
Your answer
How long have you owned or cared for this horse? *
Your answer
How do you use your horse? (Pleasure, pet, roping, dressage, etc.) *
Your answer
Primary reason for seeking bodywork on your horse? *
Your answer
Previous pertinent history: showing, work, neglect, abuse, etc. *
Your answer
In the last 3 months, describe average work: # of days worked, level of intensity *
Your answer
Do you work with a riding coach? If so, how many times/month and how long working with that person? *
Your answer
Type of saddle used?
Your answer
Have you had any saddle fit issues, or had your saddle fit checked?
Your answer
How long has horse been worked in this saddle?
Your answer
Please describe bridling/bitting used most of the time: snaffle, shank, etc.
Your answer
Hoof protection (choose one): *
Name of your hoof care practitioner/farrier, and how long they have been working on your horse.
Your answer
How often are feet trimmed/shoed?
Your answer
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
Your answer
Is your horse current on vaccines? *
Approximate date of last deworming? *
Your answer
Describe current feed program. Please include amounts of grain, cubes/hay, supplements and how much per/day *
Your answer
Does your horse typically have a lot of gas, particularly loud?
Does your horse have unusually foul smelling, or loose fecal matter on a regular basis?
Your answer
Has your horse ever been diagnosed or suspected of having gastric ulcers or hind gut issues? *
Approximate date of last equine dental exam *
Your answer
Please describe how your horse lives daily- # hrs in a stall, pasture, etc. *
Your answer
Please check boxes if your horse is sensitive to being: *
Required
Does your horse pull back when tied? *
Do you have any radiographs (x-rays) of your horse? If so, please describe. *
Your answer
Please describe any lameness issues, past or present. *
Your answer
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.
Your answer
Has your horse ever been diagnosed or treated for neurological issues, such as Wobblers, shivers, EPM, stringhalt?
Has your horse ever flipped over or fallen down?
Please describe any accident or illness not already covered that was serious enough to make you not ride the horse for even a day.
Your answer
Is there anything else you would like to tell me about your horse?
Your answer
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