Medical History Form

The next step: Fill out the medical history form

This digital medical history form is part of the overall medical history. You can fill out this section at your own pace and in your own time prior to the session. The additional medical history will be discussed and completed together during the consultation, in the presence of the horse. All information provided will be treated with care and confidentiality and will never be shared with third parties without your express consent. Do you have multiple horses for a session? Please fill out a separate form for each horse.

Owner/Caretaker Information

Your name(Required)

First name Last name

Your address

Street + house number Address line 2 Location Zip code

Your email address(Required)

Email Address Confirm Email Address

Your phone(Required)

Stable / Horse's location

Street + house number Address line 2 Location Zip code

(if different from the address above)

About the horse

Horse's name

Gender

Is the mare pregnant or foaling?

How long?

How long has the mare been pregnant, or how old is the foal?

Age of the horse

Horse breed

Discipline

Please list your horse’s medical history here, including details of any injuries, trauma, skin rashes, accidents, etc.

Describe any problems you may be experiencing with your horse:

Dentist's name – Term – Last visit:

Veterinarian's name – Term – Last visit:

Farrier's name – Term – Last visit:

Type of therapy – Duration – Last visit:

Do you have any comments or questions?

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