Client Intake Questionnaire

Client Intake Questionnaire

Simply Equine Solutions Bodywork
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Barn Location*
Barn name and address
Trainer*
What is the purpose of this session?*
What are you looking to accomplish by having me work on your horse?

Horse Information
Horse (s) Name*
Breed
Age *
Gender*

MareGeldingStallion

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The more I know about your horse the more I can help
What discipline(s) is your horse trained in? Are you aware of what your horse did previously to your ownership?*
Include how many years you have been together
What is your horse's living environment, housing, turn-out, boarding facility or home?*
Include how many hours in turn out, group turnout or private turnout or no turnout/Stall size if stalled
What is your horse being fed? Include how many times per day + supplements
What is the #1 challenge you are currently facing with your horse?
Any notable long or short-term health issues, injuries, or behavioral concerns/changes?
If yes, how long has it been since you noticed
When was the last time your horse's tack and saddle were checked?
If yes, how long has it been since you noticed
When was your horse last shod or trimmed?*
Pleases indicate shod or barefoot
When was the last time your horse's teeth were addressed, looked at, and/or floated? Did they use power tools?*
When was the last time your horse was seen by a veterinarian and why?*
Any meds prescribed or other protocol
Other than your vet, is your horse under the care of any other equine healthcare professional(s)? (for example: acupuncturist, chiropractor, homeopath, other bodywork modality, etc.)*
What are your goals for your horse (e.g. training, competing, health, etc.)*
What is your #1 goal for YOU and your horse together?*
Is there anything else I need to know about your horse? Comments? Concerns?*
Bodywork sessions vary each time, there is no One and Done method. Are you committed to at least 6mos of regular bodywork sessions?*
Intervals of sessions will vary depending on each horse.
DISCLAIMER:

I understand that equine massage, bodywork, energy work, micro-current therapy is never a replacement for proper veterinary care. I understand that my practitioner will not diagnose conditions, attempt chiropractic adjustments, or prescribe medications for my horse. If my horse is currently under the care of a veterinarian for the recovery of an illness or injury, I have cleared this work with him/her to ensure that alternative modalities are appropriate for my horse at this time. I, being the authorized agent or owner of this horse, have read and understand the bodywork form. I understand that bodywork is not a substitute for veterinary care and that it is my responsibility to consult with a veterinarian regarding complimentary care for my horse. I HEREBY RELEASE, WAIVE, AND FOREVER DISCHARGE the above names Equine Massage Therapist/Bodyworker from all claims, demands, actions, and causes of action of any kind or nature.
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Client Intake Questionnaire

Horse Information

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