Intake Form

**Please note that if you are a new client, you will be added to the Inhand app. This app will have the same intake form on it with the release forms digitally on that app. Please don’t go to the trouble of filling out this intake form twice. This form is available here on the website for those that choose to opt out of the Inhand app. Haven’t seen the credentials come on your email for the app? Please reach out to your Inhand therapist.**

Client information:

Owner of horse/dog

Agent or Lessor or horse/dog (if different from owner)

Address

Animal Information:

Horse or dog?
HorseDog

How long have you owned this animal?

Equine Breed

Dog Breed

Sex (Equine)

Sex (Canine)

Color, Height and Weight

Veterinary

Is your horse’s/dog’s on any medications? If so, what are they and what is duration of those medications?

Any therapies recommended by your veterinarian? If so, what are you currently using for them?

What is your horse’s/dog’s vaccination schedule? Please indicate any reactions to vaccination

Has your horse’s/dog’s had any surgeries? Please note any scars.

Any concerns with their immune system?

Any concerns with their respiratory system?

Does your veterinarian know you’ve chosen bodywork for your horse’s/dog’s?
YesNo

If female, is your horse’s/dog’s pregnant?
YesNo

Has she had any babies?
YesNo

What are her heat cycles like?

Farrier

Dental

Dentist

Training

Trainer

Work Load. Please indicate how many days a week horse is worked.

Has your training program changed lately?
YesNo

If Yes, how so?

Does your horse like to work?
YesNo

If No, what behaviors do they exhibit in training?

Planned competition level, and how soon do you plan on achieving this goal?

Please indicate the footing your horse’s/dog’s works on.

What is your horse’s/dog’s’s stress level from 1-10? (1 being no stress and 10 being high stress)

Tack

Tack Fitter

Have you had your tack fitted and if so, when was the last time?

Does your horse exhibit any behavior while being tacked?
YesNo

If Yes, please specify

Environment:

What environment does your horse currently live in

Does your horse’s/dog’s like it’s currently environment?
YesNo

What are the social dynamics in the environment your horse’s/dog’s lives in? (ie top of the herd or bottom and is it established or fluctuating)

Have any of the horse’s/dog’s environment changed lately

Nutrition

What is your horse’s/dog’s digestion like? Please indicate any if stool and urine are normal.

Alternative therapy

Have you tried an alternative therapy before?
YesNo

If Yes, what modality

General Health

Please rate your horse’s/dog’ss general health on a scale of 1-10. (1 being very poor and 10 being very good)

Have you dealt with this problem before?
YesNo

If Yes, for how long or how long ago?

What has been tried to relieve symptoms and what were the results?

Does your horse’s/dog’s have any edema anywhere?
YesNo

If Yes, where (ie wind puffs)

Does your horse exhibit any unusual sweat patterns?
YesNo

If Yes, where and when?

Does your horse’s/dog’s have any vices?
YesNo

What are they? (ie, herd bound, cribbing, biting, kicking, rearing etc…)

Does your horse prefer to be:
TiedCross tiedHandledNo preference

Does your horse need a friend in the barn with them?
YesNo

Is your horse’s/dog’s okay to be touched all over?
YesNo

If No, where do they not like to be touched?

Is your horse’s/dog’s okay with new people?
YesNo

Equine/Canine bodywork is not a replacement for veterinary medicine and animals with lameness or illness should be evaluated by a veterinary professional before starting a bodywork regime. Inhand assumes no responsibility for information not presented by animal owner, agent, lessor or caregiver.

I agree I have completed the form with all pertinent information and have read the disclaimer on equine/canine bodywork. *
YesNo

Signature of owner/agent/lessor