Nutritional Consultation History Form | Four Oaks Equine Nutrition

How did you find me?

Client Information

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Email Address

Horse Information

Horse's Name

Age

Gender

Breed

Color

Years with Owner

Imported

Date of Import

If yes above, when was the horse imported?

Hands

Approximate Weight

Concerns

Owner Description of Issues

Unusual BehaviorsAny unusual behaviors not listed above?

How often fed?Once a dayTwice a dayThree times a dayFour times a day

Where is horse fed?StallField, secure from other horsesField, not secure from other horses

How much hay does the horse get? (Type and how often)

Each feed with weight

What supplements does horse get? (List name, how much and how often)

General Health Questions

My horse is:

Horse's coat is:

The mane condition:

Thin and slow growingNormalFull and grows fast

Manure Texture

Energy level at rest:ActiveLethargic

Energy level while ridingActiveLethargic

Hydration level (pinch skin fold at neck and point of shoulder). Does it return to baseline in < 3 seconds?YesNo

Back above adrenals sensitive?YesNo

Is your horse nervous or anxious?YesNo

Does your horse tend to get allergies or infections?YesNo

Is your horse more sensitive to flies that other horses?YesNo

Does your horse attract more flies that other horses?YesNo

Specific Health Questions

Coat quality:

Does your horse's eyes have:

History of InjuryInfectionCloudy LensUveitis

Your horse's teeth condition:

Missing TeethHistory of Mouth InfectionsDifficulty Chewing

Your horse's respiratory health is:

NormalHistory of Respiratory InfectionsBreathing Disorder (Heaves)

Your horse's gut health is:

NormalHistory of ColicHistory of Ulcers

Your horse's skin is:

NormalProne to allergic reactionsHivesFungal/bacterial infections (rain rot, scratches)

Does your horse have joint:

Normal, No Joint IssuesArthritisInjuriesOther (list in the Other Injuries field below)

List any types of illnesses or injuries that are not listed above.

Tested for Lyme disease:

If tested for Lyme, please email titer report. Which test was done?

Tested for EPM:

If tested positive for EPM, please email titer report. Describe the behavioral neurological exam findings.

Please describe vaccination history.

Please describe medication history for medications listed: Anti-inflammatories, Antibiotics, Antifungals, Ulcer medications, Topical medications, any other medications.

Please describe worming history.

Please describe dental history.

Hoof care history:BarefootShod

Describe how often horse is seen by farrier, and any concerns or comments by farrier.

Current Exercise Regimen

Days per week ridden:

Minutes Ridden per Ride

Attitude tacking up:

Attitude during ride:

Horse's energy level while riding is:

Horse's current housing regimen:

How many hours per day is the horse stalled?

Water SourceIn StallIn Field

Free choice loose saltYesNo

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