PETFAX Equine Behavior Fax Sheet
INSTRUCTIONS:
The owner/trainer should fill out the following
form thoroughly yet concisely. PLEASE ANSWER
EACH QUESTION DIRECTLY ON THIS FORM IN THE SPACE
PROVIDED. LIMIT ADDITIONAL INFORMATION
TO ONE TYPEWRITTEN PAGE IF NECESSARY. Print
out and fax both the completed Behavior Fax Sheet
and the Initial Consultation
Request Form to 1-508-839-8734. If you
have questions, call 1-508-887-4640.
| Date:
|
Recorder: |
| Name
& Address of Owner: |
| Email Address: |
| Telephone: |
Fax: |
| Name
& Address of Trainer: |
| Telephone: |
Fax: |
| Name
of Horse: |
Breed: |
| Principle
use of Horse: |
| Age
of Horse: |
Age
at which horse was acquired: |
| Weight:
Color:
Sex:
Gelded/ovariectomized: |
| Any
behavioral changes following gelding/ovariectomy?
|
Date
of last physical examination:
(Please include copies of any relevant medical
records and/or blood work.) |
| Any
medical problems? |
| Any
current medication (please include dose
if known)? |
| WHAT
IS YOUR HORSE'S BEHAVIOR PROBLEM ? |
| Age
of onset: |
| Duration
of each incident: |
| Frequency
of occurrence: |
| Have
there been any changes in the pattern, frequency,
intensity and/or length of incidents from
the time of onset to the present? |
| Are
there any specific conditions which seem
to trigger the behavior? |
| Can
the horse be interrupted when engaged in
the behavior? |
| How
long is the interval between the behavior
stopping and the beginning of the next occurrence? |
| Describe
any methods used to stop the behavior and
the horse's response to these methods: |
| Please
give a detailed description of the last
time this problem occurred: |
| HORSE'S
HISTORY |
| Where
did the horse come from? |
| What
was his/her former use if different from
present? |
| Was
horse obtained for different purpose than
his current use?: |
| Number
of former owners (approximate): |
| Do
you know if related horses showed similar
behavior to this one. Did they show any
other abnormal behaviors of which you are
aware? |
| HORSE'S
ENVIRONMENT |
| Type
of housing (stall [standing or loosebox],
pasture, runout shed): |
| Hours
and type of exercise per day: |
| Exercised
every day?: |
| Hours
of turn-out per day: |
| Type
of bit used, martingale, other training
aids: |
| Other
horses with which horse interacts (list
age, sex and type of contact): |
| Relationship
between horse and other horses (friendly,
aggressive, neutral): |
| Does
horse attempt to herd others? |
| Other
animals in environment: |
| DIET
(How much and how often) |
| Grain: |
| Hay: |
| Food
Additives/supplements: |
| Pasture
(type): |
| Water
consumption: |
| TRAINING |
| Age at weaning: |
| Age at which
halter broken: |
| Broken to
harness/saddle: |
| BEHAVIOR
PROBLEMS (Describe where appropriate) |
| Shying
-- how often and at what: |
| Phobias/abnormal
fears: |
| Head
shy/resentful of grooming/handling: |
Aggression
towards humans or other animals:
1) In stall/barn:
2) Outside stall/barn:
|
| Misbehavior
under saddle: |
| Problems
being led: |
Barn
vices (check where appropriate):
| ____
cribbing |
____
wood chewing |
____
pawing |
____
kicking stall |
| ____
windsucking |
____
flank chewing |
____
pacing |
____
circling |
| ____
refusing to tie |
____
headbobbing |
____
weaving |
|
|
| Abnormal
sexual behavior (excessive, inadequate,
inappropriate): |
| Abnormal
maternal behavior (excessive, inadequate,
inappropriate): |
| Manure
eating: |
| Please
list people who work with/ride horse. Include
amount of time spent with the horse and
the type of work done. If school horse,
level(s) of riding: |
| Please provide the following information about your horse’s local veterinarian:
|
| Name:
|
| Business Address:
|
| Phone Number:
|
| How did you hear about Tufts Animal Behavior Clinic?:
|
Thank
you for using PetFax.
|