Two Legs and Four Holistic Health - Large Animal Questionnaire

In order to prescribe the best prescription, I depend on your co-operation. Homeopathic treatment is mainly based on the symptoms you provide me. If I am to make a successful prescription, I must know all the details of your horse's problems. I must also understand them as an individual, including their reactions to stress, their past, their nature and their mental make up.

The information you provide enables me to restore their health. So please be frank and free with all relevant information.

Please read each question carefully. Don't keep anything back. Everything you tell me is in complete confidence. This is a lengthy questionnaire, so be prepared to take time to fill it out.

Rather than use he/she, I use the term 'them', 'they'.

You can save the document to complete later. Make sure you click on 'Submit' at the end.

You can fill out as much or as little as you desire. However, the more info I have the better able I can help. Health is complicated and many factors contribute to ill health. Homeopathy examine every possibility.

PLEASE NOTE - THIS FORM DOES NOT AUTOSAVE. YOU HAVE TO CLICK ON THE SAVE BUTTON AT THE END IF YOU NEED TO COME BACK LATER TO FINISH IT

Date*

MonthDayYear

Your name*

First NameLast Name

Preferred Name

Your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Landline Phone

Area CodePhone Number

Cell/Mobile Phone

Area CodePhone Number

E-mail*

Connecting for consultation*

OnlineVisit to clinic

How did you hear about me?

If other, please explain

Your horse's name*

Your horse's breed

Your horse's date of birth or age if known

MonthDayYear

What sex?*

GeldingMareStallionFoal/filly/colt

How long have you had your horse?*

Where did they come from?

BreederRescuePrivate from advertisementOther

Comments

How long did it take them to settle in?

Describe the chief complaint*

Are there any other complaints or concerns?

How do they affect their life?

Please list the medications and health supplements you are administering*

Did something trigger the change in health?

When did the problem/s start originally?

Are they adversely affected by

Comments

Please list past health problems/injuries/traumas and the approximate age

	Type	Rough age	Duration	Treatment
Health issues
Health issues
Major injuries
Major Injuries
Shock
Shock
Other

Comments

General Health, if not part of the problem already detailed


How is the digestion?
What is the stool like?
How many stools in a day?
Is there constipation?
Is there diarrhoea?
What is their thirst like?
Do they suffer with colic?
Do you use a commercial insect repellent?
Do you use a commercial wormer?
Other

Comments

Chemical exposure such as pasture pesticides, weed killers, fertilisers, washes, etc

	Name	Date	Effect
Pasture fertiliser?
Pasture fertiliser?
Weed killer?
Weed killer?
Washes?
Other

Comments

Drugs

	Name	Date	Date	Date	Date	Date	Date
Corticosteroids
Antibiotics
Other

Comments

Vaccines

	Name	Date	Date	Date	Date	Date	Date
Rabies
Influenza
Sleeping sickness
Herpes virus
Strangles
West Nile Virus
Tetanus
Other

Comments, adverse reactions, slow recovery, etc

Please list any surgeries

	Age/Date
Gelded
Injury
Other?

Comments, adverse reactions, slow recovery, etc

	Yes/No
Out at pasture full time
Part time pasture
Companions
Additional hay
Additional hard feed
Full time stabled
Other

Comments

Sleep


Soundly
Restless
Twitching
Snores
Dozes well on 3 legs
Other

Comments

How is the relationship with other animals

Has your horse been treated by a homeopath previously? If so, what were the remedies used?

If you have used homeopathic remedies on your horse yourself, please give details and the effect.

What other natural therapies have been used on your horse?

Two Legs and Four Holistic Health - Large Animal Questionnaire

Current Health Concerns

Environment, Past Health Issues

Chemical, Drug, Vaccine, Surgery History

Lifestyle and Diet

Past Holistic or Natural Treatment

Thank you!

Re-scheduling or Cancellations