New client history form

ROBIN FOSTER HORSE BEHAVIORIST

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HISTORY FORM FOR NEW CLIENTS

* Indicates required field

Are you contacting us for a legal reason (injury, property damage, abuse/neglect)? *

yes no

GENERAL INFORMATION

Address *

Line 1

Line 2

City

State

Zip Code

Country

Consultation date (mm/dd/yy) *

Horse name *

Name *

First

Last

Phone Number *

Breed *

Age *

Sex *

Mare / Filly Gelding Stallion / Colt

Email *

PRIMARY BEHAVIOR CONCERN

What is the primary problem you are experiencing with your horse? Please explain. *

How often does the problem occur? *

When did the problem begin? How long has it been going on? *

What measures have you taken to manage the problem before contacting us? *

VETERINARY INFORMATION

Who is your veterinarian? *

Is your horse currently taking medication? If so, please list which medications, how often, and for how long. *

Answer "no" if you pet is not currently taking medications.

Have you consulted with your veterinarian about this issue? *

Yes No

If yes, what was your veterinarian's assessment and recommendation? *

HISTORY

How long have you owned this horse? *

How old was the horse when you got it? *

From whom did you get this horse? Please describe briefly. *

What do you know about the horse's history before you became the owner? *

Do you know of any pre-existing issues or traumatic events in the horse's life? Describe them here briefly. *

CURRENT ROUTINE

Activities.

Daily routine. How does your horse spend a typical day? (please describe) *

How much time does your horse spend socializing/interacting with other horses? Describe briefly. *

How much time spent alone? Please describe. *

How much and what kind of training? *

Has your horse experienced any recent life changes (medical, social, living arrangements)? *

Feeding.

What do you feed your horse? Please be specific. *

What is the daily feeding schedule? *

Does your horse have any dietary restrictions or food allergies/sensitivities? *

Please type "no" if your pet does not have any diet restrictions.

Do you give your horse treats? What kind and how often? Do you feed treats by hand? *

Please type "no" if you do not supplement meals with treats.

INCIDENTS
Describe up to FOUR recent and/or major incidents with your horse related to the behavior issue. Please include the following information in the spaces below: (1) When did the incident happen? If you don't remember the exact date, please estimate to the best of your knowledge. (2) What events lead up to the incident? (What were you and/or your horse doing? Where did it occur? What people or animals were around? etc.) (3) How did you react to it and manage the incident? (4) Did it result in injury to your horse or another animal or human? If so, how extensive were the injuries?

Incident #1 (required)

Incident #1-Date (mm/dd/yy) *

Incident #1-Did it result in injury to an animal or human? *

yes no

Incident #1-What happened? *

Incident #1-What events led up to the incident? *

Incident #1-How did you react to and manage the situation? *

Incident #1-Describe any injuries. *

Incident #2

Incident #2-Date (mm/dd/yy) *

Incident #2-Did it result in injury to an animal or human? *

yes no

Incident #2-What happened? *

Incident #2-What events led up to the incident? *

Incident #2-How did you react to and manage the situation? *

Incident #2-Describe any injuries. *

Incident #3

Incident #3-Date (mm/dd/yy) *

Incident #3-Did it result in injury to an animal or human? *

yes no

Incident #3-What happened? *

Incident #3-Describe any injuries. *

Incident #3-What events led up to the incident? *

Incident #3-How did you react to and manage the situation? *

Incident #4

Incident #4-Date (mm/dd/yy) *

Incident #4-Did it result in injury to an animal or human? *

yes no

Incident #4-What happened? *

Incident #4-What events led up to the incident? *

Incident #4-How did you react to and manage the situation? *

Incident #4-Describe any injuries. *

ADDITIONAL REMARKS

Is there anything else you would like us to know? *

THANK YOU!

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Home
Shawna Karrasch Clinic
Services
Contact Us
Behavior Bites
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