IWP Questionnaire
Client Name
*
First Name
Last Name
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address where horse is kept
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Horse's Name
Does he/she have a registered/show name?
Yes
No
Show Name
What breed is he/she?
How old is he/she?
This age is
Estimated
Exact/from papers
Does he/she have any tattoos or brands?
Yes
No
Tattoo/brand
How long have you owned him/her?
Was he/she imported?
Yes
No
When?
If it is a male, is he gelded?
Yes
No
If it is a mare, has she ever produced a foal?
Yes
No
Do you have plans to breed in the future?
Yes
No
Does she exhibit “mare-ish” behaviors during heat cycles?
Yes
No
Any treatment administered for that behavior?
Yes
No
Does he/she have any vices (cribbing, weaving, etc.)?
Does he/she have any behavioral concerns?
Needle-shy?
Yes
No
Has he/she ever been described as a “light-weight” for sedation?
Yes
No
Does he/she exhibit any of the following signs? (please check all that apply)
Shaggy coat/delayed shedding
Laminitis past/present
Increased thirst/urination
Other recurrent infections (hoof abscesses, skin, eyes, teeth, sinus, etc.)
Recent transition from easy to hard keeper
Overly easy keeper
Change in attitude
Regional fat deposition
Exercise intolerance
BCS >6/0
Abnormal sweating
Loss of muscle mass
Weight loss
Recent weight gain
Udder/sheath swelling
Girthiness
Teeth grinding
Poor appetite for grain
Dull/poor coat quality
Dislike of brushing/blanketing
Flank sensitivity
Resistance under saddle
Is your horse currently on any medications?
When were the last vaccines given and what were they?
Does this horse have a history of vaccine reactions?
When was the last dental performed?
By who?
When/what was the last anthelminthic treatment administered?
Was this based on a fecal egg count?
Is he/she on a regular farriery schedule?
Who is your farrier?
Any foot concerns from you or your farrier?
Is he/she on a sand prevention program?
Does the horse have a current coggins?
Expiration date?
Is this horse microchipped?
Yes
No
Would you like him/her to be?
Yes
No
Is this horse insured?
Major medical and surgical coverage?
If not, is the horse eligible?
If not, would you like to have the horse covered for colic surgery?
Does this horse have any history of colic?
Yes
No
If yes, please describe the circumstances:
Has your horse been historically treated for unsoundness?
Yes
No
If yes, please describe the circumstances:
Any history of surgery?
Other relevant medical history?
Any history of allergies to feeds, medications, etc.?
Do you show or compete this horse?
If yes, what discipline do you do?
Does the horse ever travel for leisure (camping, trail riding, etc.)?
Yes
No
How often?
Check the box that best describes the horse's work load:
Idle/occasional (less than 1x/week, primarily walking with occasional trot/canter)
Light (2-3x/wk, less than 20-40 min., light W/T/C or easy trail rides)
Moderate (4-5x/wk, 30-60 min., W/T/C with occasional jumping, pattern work, etc.)
Heavy (5-7x/wk, >60 min., regularly galloping, jumping, endurance, racing, etc.)
Please describe the horse’s diet (grain/hay amounts, # feedings/day):
Please describe the horse’s turnout situation (grass/sand, size, hours per day,alone vs. with friends):
Is the horse on any supplements?
Would you be interested discussing holistic or complementary therapies for this horse?
Submit
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