Equine Medical History Form

Columbia Integrative Veterinary Therapy, LLC

Equine Patient Medical History and Client Information Form
Client Name*

First NameLast Name
Client Address*

Street Address

PO Box

CityState / Province

Postal / Zip Code
Barn Address

Barn Name

Street Address

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Can we text you?

YesNoOther
Email*
example@example.com
Can we discuss your horses condition with anyone else? If so, who? (ie. family, trainer)
Regular Veterinarian
ie. Dr. Smith, Sound Equine
Vet's Phone Number

Area CodePhone Number
Farrier
Farrier's Phone Number

Area CodePhone Number
Horses Name:*
Horses Age*
Horses Breed*
Horses Sex*
Mare, Gelding, Stallion
Horse reproductive status
ie. pregnant, not pregnant, breeding stallion, currently being bred
Horses primary job*
Current level of competition
What is the primary reason you are seeking acupuncture treatment for your horse?*
How long has this issue been going on?*
Are they currently on exercise restriction?
ie. strict stall rest
What is your expectation from your horses acupuncture treatments?*
Please give a detailed history regarding this concern, including any veterinary workup or diagnostics (ie. x-rays, joint injections)*
Current Medications (drug, amount, frequency, duration, is it helping?)
ie. Bute 1 gram once a day for 2 weeks, not comfortable without it
Past or common medical issues

Mild colicSevere ColicColic surgeryOCD - congenital bone or joint issuesItchyDental problemsLamenessCushingsLaminitisEye problemsCoughRoarer/Laryngeal ParalysisEpistaxis/NosebleedsPoor hoof qualityNavicular syndromeDiarrheaHas had a foalHoof AbscessesOther
Past medical history detail
Diet (type of feeds, frequency and amount) *
ie. 2 flakes local hay, 1 lb equine senior, twice daily
How is their appetite?
ie. normal/good, decreased, increased, picky
Current supplements or herbal treatments? (type, amount, frequency, duration)
ie. Horseguard vitamin, labeled dose, daily, 6 mo
Amount, type and frequency of turnout *
ie. pasture access 24/7 or small run, no pasture
Are they turned out with other horses?
Do they get along with other horses?
Current exercise program (frequency and duration of exercise, what type of work)*
ie. ridden 3-4 times a week for 45 min, arena work
Has your horse had any joint injections? Please, indicate which joint.
ie. hock injections annually
Has your horse ever had surgery? Please describe.
Does your horse have any behavioral issues or resistance to any maneuvers under saddle? Please describe.
Is your horse cinchy?
If you have a mare, how is she during her heat cycle?
ie. don't notice, manageable or really irritated
My horses energy level in general is:

NormalHyperactiveSluggishReduced from normalIncreased from normalOther
Energy is highest

MorningDaytimeEveningConsistentOther
I would describe my horses personality as (select all that apply):

A goofballCalm and consistentFireyWitchyLaid backSpookyCuriousFriendlyIndifferent/AloofAlphaLow in the pecking orderAggressiveOutgoingShyQuestioning/hard time trustingDepends on the day/InconsistentCompetitiveOther
My horses attitude is:

HappyAgitatedContentRestlessCrabbyDepressedOther
My horses stools are:

Normal, formedSoft, formedSoftSoft under stress, otherwise normalDry/hardDiarrheaOther
Does their stool have a strong odor?
Do they have gas?
My horses urination is:

NormalIncreasedDecreasedOther
Does the urine have a strong odor?
What is the color of the urine?
ie. dark, normal, light
My horses thirst is:

NormalIncreasedDecreasedOther
Does your horse have difficulty eating?
When was their last dental float/exam?
My horses hooves are:

Strong, hold shoes wellThin walledHave cracksSoftTenderDry/brittleGrow slowlyNormalOther
How often are they trimmed/shod?
Is your horse itchy? Is this during a specific time of year?
Does your horse have dry skin/flakey skin?
Are there hair coat changes? If so, explain.
Does your horse cough or have difficulty breathing? If so, explain.
Does your horse have any lameness issues? Please describe.
Do you think your horses is in pain? Can you rate this pain from 1-10?
How is your horse generally with the vet?
How is your horse generally with the farrier?
Anything else you'd like us to know?
I hereby authorize Dr. Kelby Myers to perform any combination of dry needle acupuncture, electrical stimulation of needles, acupressure, lacer, massage therapy, physical therapy or herbal or supplement recommendation that she deems necessary for the treatment of my animal blanks. I am aware that there are inherent risks with any procedure, and the nature and purpose of the above-listed procedures, as well as any potential side effects, have been fully disclosed. I understand that these treatments are considered complementary or alternative medicine and are not a substitute for conventional Western medicine. I acknowledge that no guarantee of results has been made.
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Columbia Integrative Veterinary Therapy, LLC