Horse History Form

Registered Name:

Barn Name:

Breed:

Date of birth:

Sex:

Color:

Other Markings / Brands / Tattoos:

Use/Career:

Primary Concern:

When did you first notice the issue?:

Was there an inciting incident?: (i.e. a specific event or accident that may have caused the issue)

Yes

If yes, please describe:

Has the issue improved, stayed the same, or gotten worse?:

Horse's Current Level of Work:

Does the issue improve with work/does the horse work out of it?:

Under what condition(s) is the issue most obvious?:

Has the horse been seen for this issue previously?:

Yes

If yes, by whom and when?:

Previous Treatments?:

Yes

If yes, what treatments?:

Treatment Outcome(s)?: (i.e. Did any treatments improve the issue?)

What medications and/or supplements is the horse currently on? When was the last dose administered for each?:

Additional Information:

Referring or Primary Care Veterinarian:

Email:

Phone:

Signature:

Sign above

Date: