EmailMe Form - Equine Acupuncture Questionnaire

Horse's Name

What are the main
symptoms that concern
you right now and when did
you first notice them?

Please describe any
work-up for this problem
that has taken place so far.

Please list all current
medications and
supplements

Current diet...hay, grain,
pasture.

Describe any previous
illness, lameness or
surgeries.

Which of these examples
best describes your horse's
personality?

Fast moving, excitable, friendly to everyone, social butterfly, doesn’t like to be alone, may be prone to separation anxiety, sensitive.

Friendly, mellow, calm, slow moving, food oriented, sweet and tolerant, caring or nurturing, may tend to be overweight

Aloof, dignified, stand-offish, busy doing his or her own stuff, likes set routines, likes people, but doesn’t really need them. May tend to grieve after major changes or losses.

Shy, worried, alert, noise sensitive, fearful in strange places, around strange people or strange noises

Bossy, athletic, likes to perform, assertive, likes to be in charge, competitive, takes the lead, may have a tendency to be irritable.

Do you have any other
current concerns or any
other information that you
feel may be useful?