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Equine

Behavioral History

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The information you provide below will be used during your consultation to develop a diagnosis and plan of treatment. Please fill it out as completely as you can. All information will be held in strict confidence and will not be released to any third party without your written consent.

Please submit at least 2 business days prior to your horse’s appointment.
Today's Date
MM slash DD slash YYYY
Please tell us who referred you:
Your Contact Information
Owner's Name
First Last
Phone Numbers
Phone
Phone
Phone
Address
Street Address Address Line 2 City State ZIP Code
Email

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Your Family Veterinarian’s Contact Information
Doctor's Name
Clinic Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Veterinarian’s Phone Number
Veterinarian’s Fax Number

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Your Horse’s Information
Horse’s Name
Breed
Age
Sex
Color

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Main Behavior Problem
Chief complaint? When did the problem begin?
The main problem occurs when? (check off below):
When the horse is alone.
- Always
- Usually
- Rarely
- Never
In the presence of other horses.
- Always
- Usually
- Rarely
- Never
In the presence of the owner.
- Always
- Usually
- Rarely
- Never
In the absence of the owner (other people present).
- Always
- Usually
- Rarely
- Never
In the stall.
- Always
- Usually
- Rarely
- Never
In the pasture.
- Always
- Usually
- Rarely
- Never
At competitions or group events.
- Always
- Usually
- Rarely
- Never
Under saddle or at work.
- Always
- Usually
- Rarely
- Never
Prior to feeding.
- Always
- Usually
- Rarely
- Never
During feeding.
- Always
- Usually
- Rarely
- Never
After feeding.
- Always
- Usually
- Rarely
- Never
How often does this behavior occur?
- Daily
- Weekly
- Monthly
Has there been a change in the frequency, intensity of appearance of the problem?
What has been done so far to correct the problem?
What has been the horse's response to the correction?
Has anything changed in this horse’s environment prior to the appearance of the problem (new stall, new barn, new feed, new horses, new saddle, etc.?)

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Horse's Environment
Type of housing (stall, pasture, run-out shed)?
Diet: Grain type? Hay type?
What supplements is this horse on?
Exercise (hrs. per wk. ridden/ hrs. per wk. in paddock)?
Type of bit used?
Type of saddle used?
Other horses in environment and relations between horses (friendly, aggressive, neutral)?
Other animals in environment?
Primary caretaker of this horse.
Primary trainer of this horse?
Do you compete with this horse? What discipline?

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Early History
Why was horse obtained? Is it still used for this purpose
Source of Animal?
Age at weaning?
Age when obtained by present owner?
Were there previous owners?
- Yes
- No
- N/A
Do related horses have similar problems?
- Yes
- No
- N/A

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Education
Age at halter breaking?
Method of training to saddle or harness, age when training began?
Other types of training methods? (driving, jumping, dressage, games, trail riding, cutting)

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Other Behavior Problems
Please Describe
Shying, how often and at what?
Any other phobias?
Head shy?
Resentful of grooming/ handling (brushing, hoof picking clipping, etc.)?
Difficult to handle when hoof trimming or shoeing?
Difficult to load or trailer?
Aggression towards humans or animals (dogs, cows, etc.) including threatens, strikes, bites, kicks, chases)?
Aggression toward other horses (threatens, strikes, bites, kicks, chases)?

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Misbehavior Under Saddle
Check appropriate behavior
- Moves while rider mounts
- Backs in harness
- Bucks
- Rears
- Wrings tail
- Sensitive to saddling, girth tightening
- Wants to lead or will only follow other horses
- Runs away when approached
- Slow to leave and quick to return to barn
- Hard to get or keep on right or left lead
Barn Vices
Check all appropriate and describe frequency
- Aggressive in stall (pins ears, threatens)
- Cribs
- Chews wood
- Food aggressive
- Kicks stall
- Paws
- Paces
Sexual behavior: excessive, inadequate, abnormal? Describe.
Maternal behavior: excessive, inadequate, abnormal? Describe.

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Physical History
Current medical problems?
Past medical problems (surgical or medical)?
Medication history?
Results of diagnostic tests (radiographs, blood work)?
How often are the teeth floated? When was the last float?

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Grand Rapids, MI 49505
(616) 264-2695
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Novi, MI 48375

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