New Client Form - Horses
Horse's Name:
Owner's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
What is the main skin problem with your horse?
At what age was this condition first noticed?
Have there ever been any previous skin problems?
Yes
No
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Symptoms
Have any of the following been observed?
sores
scabs
dandruff
hair loss
odour
hives
heat
redness
diarrhoea
tiredness
tiredness
weight loss
weight gain
depression
ear infections
increased appetite
increased thirst
Does your horse
rub at the face
head shake
scratch/rub at ears
bite the limbs
scratch at the flanks
bite the stomach area
roll on the back
bite at the tail area/anus
rub against tree/post
eye discharge
sneeze
wheeze or cough
Other
Other Detail (if required)
Do the symptons vary?
If the dermatitis has been present for some time, are the symptoms worse in :
Spring
Summer
Autumn
Winter
Are there symptoms present all year round?
Yes
No
If yes, would there be a time of no symptoms at some stage?
Yes
No
What (if anything), causes a worsening of symptoms?
What helps?
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Environment Details:
Are there other in contact animals?
Yes
No
If so, How Many?
Other
Environment Details
Do you know of any relatives of this horse that have skin problems?
Yes
No
Does any in contact human have skin problems?
Yes
No
Please estimate:
What percentage of time does your horse spend in the
Stable
%
Paddock
%
Do you swim your horse?
Yes
No
If so how often?
And where?
river
dam
beach
Other
What type of stable bedding?
What type of paddock?
sand
bush
pasture
If Pasture what type?
Where do you exercise your horse and how often?
Is your horse rugged?
Yes
No
What type of rug?
How often are the rugs cleaned?
When cleaning rugs, do you:
Wash
Dry Clean
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Bathing
Does Bathing ...
Help
Worsen
Make No Difference
What type of shampoo are you using?
How often do you wash your horse?
Weekly
Monthly
Rarely
Other
Insects
What is the current fly/insect repellent for your horse?
How frequently do you use this product?
Is fly/insect repellent used on other in contact animals?
What insects do you see in your horses' environment?
Mosquitos
Flies
Ants
Cockroaches
Moths
Medications
Do you know what previous medications have been used?
Rinses
Injections
Paste/Granules
Ointments, lotions etc
Ear Drops
What are the names and dose of any medications? (please list)
Last rinse used
-
Day
-
Month
Year
Date
Last date injection given
-
Day
-
Month
Year
Date
Last Paste/Granules given
-
Day
-
Month
Year
Date
Last ointments/lotions used
-
Day
-
Month
Year
Date
Last ear drops used
-
Day
-
Month
Year
Date
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Diet
What do you normally feed your horse?
Hay
Hard/grain feed
Grazing only
If hay which types?
Meadow
Oaten
Lucerne
Other
If grain, what types of grain?
If grazing, what types of pasture?
What supplements, if any? (e.g. vitamins, fatty acids, glucosamine etc)
What do you give your horse for snacks or treats?
Have you ever fed a special diet?
Yes
No
If yes, what diet?
General Health
Have there been any episodes of:
Colic
Scouring/diarrhoea
Mucous stools
Lethargy
Increased water intake
Increased appetite
Weight Gain
Weight Loss
Weakness
Inappetence
Does your horse have any other illness?
Yes
No
Please specify and what medications are being prescribed.
What do you think could be the cause of the skin problem?
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