Intake Questionnaire

Intake Questionnaire - Horse
Thank you for booking an appointment with The Veterinary Behavior Center!

Our team is committed to helping you and your horse have a happier and healthier life together. Here you will find important information about working with us and a patient questionnaire. All information provided on these forms is strictly confidential.

We will reach out to your primary care veterinarian directly for medical records. If you have any notes from a trainer, feel free to email those to info@vetbehaviorcenter.com in advance of your appointment.

If you have scheduled an appointment for more than one animal in your care, please fill out a form for each animal.

If you have any short videos that demonstrate the behavior problem, click here to request a Dropbox link to upload them. Never incite or prolong an aggressive or stressful event just for the sake of a video - this could be a bad learning experience for your animal and may be a safety risk.

Please complete this paperwork at least 5 days before your appointment.

Additional information about our Center, including your financial investment, can be found at www.vetbehaviorcenter.com or feel free to call or email. Please let us know if you have any questions in the time leading up to your appointment.

We look forward to meeting you and your horse(s)!

- The Veterinary Behavior Center team

Date*

MonthDayYear
Date
Primary Owner/Guardian*
Secondary Owner/Guardian
Signature
Date

MonthDayYear
Date
General Background Questions
Where did you get your horse?
How old was your horse when you obtained him/her?
How many owners/guardians has your horse had prior to you?

01234+Not sure
If applicable and known, please explain what your horse was used for by their previous owners/guardians:
If applicable and known, please explain why your horse was relinquished by their previous owners/guardians:
If known, how old was your horse when it was weaned?

Lifestyle & Activity Questions
Why did you get this horse?
Are you still using your horse for this purpose? And if not, why not?
Do you currently work with a trainer? If so, please provide trainer name and approach:
How often and for how long is your horse ridden or worked each week? Describe the type of exercise and your horse's weekly exercise routine.
List any equipment you use for the above types of exercise:
If known, what method was used to train to saddle or harness and at what age:
Other types of training methods your horse has been exposed to:
How many people regularly interact with/ride your horse?
How many of these people are children?
How much time do you spend with your horse per day or per week?
Describe your relationship with your horse - include separate descriptions for each family member that interacts with your horse:
Describe the relationship between your horse and any non-family members that interact with your horse on a regular basis:
How is your horse housed? Check all that apply.

PastureRun-out shedStallOther
Is your horse living on your property or is he/she boarded?

My placeBoardedOther
How many horses are in the facility?
How many horses does your horse have regular physical contact with (e.g. out on pasture together)?
List other horses your horse has regular contact with and the nature of your horse's relationship with each. If too many to list focus on the ones that seem to have a significant relationship with your horse. Include their sex, neuter status and age:
List any other animals/species that live in your horse's environment and the nature of your horse's relationship with them:
Does your horse have any accessories/toys? Describe.

Medical Background
Briefly describe any past, now resolved, significant medical problems and outcomes your horse has had:
Describe any current, unresolved, ongoing medical problems:
Please list any medications your horse is currently on, including dose and frequency of administration:
Please list any supplements your horse is currently on, including dose and frequency of administration
Please list any medications or supplements your horse has tried for behavior problems in the past, including dose, frequency and how long it was given:
What do you feed your horse?
Does your horse get treats for anything? If so, what and when?

Educational Use Release
The Veterinary Behavior Center, LLC seeks permission to use any recordings, photos and videos for the purposes of diagnosis, treatment planning and monitoring as well as for educational and marketing purposes, including but not limited to lectures, webinars, presentations, printed materials and social media. When used for view in the public, no identifying information will be revealed.
Please check one of the following:

I give permission for my animal's photos and videos to be used for internal purposes, as well as for external educational and marketing purposes.I give permission for my animal's photos and videos to be used for internal purposes only. I do not give permission for my animal's photos and videos to be used for external educational or marketing purposes.
Informed Consent on Medication Use in Veterinary Behavior
Medications may be discussed or recommended in the course of treatment of behavioral problems. Many of the medications prescribed in veterinary behavior have not been approved by the FDA (Food and Drug Administration) for use in all or any animal species for all or any behavior problems. Thus, their use may be considered “off label”. This is a legal, common and well-accepted practice for veterinarians to prescribe medications in this manner. The side effects of off label usage have not been fully studied and regardless, any medication may have unexpected side effects. Not all animals will require the use of medications as part of their treatment, but we want you to be aware of this information in advance. We will make every effort to inform you of potential benefits and side effects of any medications recommended to the extent known. However, you should be aware that different animals may react differently to different medications. We welcome any questions about the use of medications in your animal's treatment plan. By signing this form you acknowledge that you have received and read this information. Signing this form in no way obligates you to using medications in the treatment of your animal.
Signature*
Name*

First NameLast Name
Today's Date:*
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Intake Questionnaire - Horse

Basic Information

General Background Questions

Lifestyle & Activity Questions

Medical Background

Behavior Problem #1

Behavior Problem #2

Behavior Problem #3

General Behavior Information

Human-Directed Aggression Screen

Additional Information

Educational Use Release

Informed Consent on Medication Use in Veterinary Behavior