PLEASE GIVE AS MUCH INFORMATION AS POSSIBLE
Owner of horse/dog
Agent or Lessor or horse/dog (if different from owner)
Address
Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe
Select State
Select City
Horse or dog? HorseDog
How long have you owned this animal?
Equine Breed
Dog Breed
Sex (Equine)Please SelectMareStallionGelding
Sex (Canine)Please SelectFemale (intact)Male (intact)Neutered maleSpayed female
Color, Height and Weight
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?
Dentist
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 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
What environment does your horse currently live in Please SelectStallStall with daily turnoutLives in small paddock aloneLives in small paddock with other horse(s)Lives in large pasture aloneLives in large pasture with other horse(s)Other
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 Please SelectStallFootingCompanionsBarn staffFeedLocation
What is your horse’s/dog’s digestion like? Please indicate any if stool and urine are normal.
Have you tried an alternative therapy before? YesNo
If Yes, what modality
Please rate your horse’s/dog’ss general health on a scale of 1-10. (1 being very poor and 10 being very good)
Are symptoms; ConstantIntermittentOnset (sudden or gradual)More noticeable under saddle (without rider)More noticeable under saddle (with rider)More noticeable on different footingsMore at onsetLess at onset
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
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