Equine Pre-Appointment VSMT History Form

Equine VSMT Initial Appointment History

In an effort to better serve you and your horse, please complete the following history at least 2 days prior to your appointment.
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Horse's name:*
Age of horse*
Breed of horse*
Use*
What grain do you feed?*

NoneOatsSweet feedSenior feedLow carbohydrateOther
What roughage does your horse receive?*

Grass hayAlfalfa/grass hay mixAlfalfa hayPastureOther
What is the name of the grain you feed?
Do you feed your horse supplements?*

YesNo
Please list all the supplements you feed:
Does your horse receive turn-out?*

YesNo
Frequency
Days/week for
Hours/day
Do you ride your horse?*

YesNo
Frequency
Days/week for
Hours/day
Do you drive your horse?*

YesNo
Frequency
Days/week for
Hours/day
What is the primary discipline for which you use your horse?*
Reason for VSMT visit:*

InjuryLamenessNeurologic conditionIllnessMaintenanceOther
Please describe your horse's condition:*
How long has your horse had this condition?*
Is this condition*

ImprovingDeterioratingStaying the same
What is the goal for your horse?*
Previous history of lameness, injuries and adjustments:*
Should be Empty:

Equine VSMT Initial Appointment History