Equine Intake Questionnaire

Thank you for contacting Free Rein Therapeutic Riding! We need a certain type of horse to accommodate our riders’ needs.

We are looking for horses that are:
• Quiet and patient
• Willing to work with anyone (male/female)

• Sound with a consistent and steady gait at the walk, jog/trot and lope/canter

• Needs minimal specialized care (feeding/shoeing/medical) outside of routine care

• Able to work up to 4 hours per day (with breaks)

• Able to work alone or with other horses

• Comfortable in both an indoor arena and on the trail

If you would like us to consider care leasing or donating your horse for our program, please complete the questionnaire.

Basic Horse Information

Horse's Registered Name:

Horse's Barn Name:

Horse's Breed:

If other, please specify breed type:

Age

Gender

Height (hands)

Weight (lbs)

Color

Horse Owner Information

Owner's Name

Owner's Email Address

Phone Number

Preferred Method of Contact

Current Mailing Address

City

State

Zip Code

Is the current physical address of the horse different than the mailing address?

If yes, what is the current address of the equine?

Additional Information

Is your horse available for: (check all that apply)

LeaseFor SaleDonationOther

Specify if other is marked:

Are you willing to sponsor your horse for the trial period for their first month's board ($400.00)

Are you willing to sponsor any amount for your horse while they are under trial?

Horse Health History

Current Veterinarian Name:

Current Veterinarian Phone:

Current Farrier Name:

Current Farrier Phone Number:

Does your horse require therapeutic shoeing?

If yes, please specify:

Do you want your horse to continue to use their current farrier? Farrier has to be willing to come to our facility.

Please indicate current or past considerations in the following areas:

	Yes	No
Vision or Eye Conditions/Issues
Heart conditions/issues
History of choke
History of colic
Arthritis
Lung issues
Previous injury that cause lameness or pain, even temporary
Diet restrictions
Exposure to strangles
Treated for strangles
Diagnosed with PPID or Cushing's Disease or Equine Metabolic Syndrome

Please explain all items marked yes:

Hoof Conditions:

Please explain all items marked yes:

Vaccination History

Please provide the vaccination(s) that your horse has received, if possible provide date(s) given the vaccination(s).

E & W Encephalitis

Date

Tetanus

Date

West Nile

Date

Rhino

Date

Rabies

Date

Influenza

Date

Vaccinations were administered by:

Other Information

Last farrier date

Is your horse

Last dental float date

Type of dental float

ManualPower

Last deworm date and which product used

Please provide the deworming schedule for the last 12 months.

Diet, please select the feed that your horse is currently receiving (select all that apply)

Provide details about the special diet:

Do you regularly feed any grain, supplements or medications?

Please list any grain, supplements or medications that you currently feed regularly:

Are you willing to provide grain and supplements that your horse is on each month?

Performance History

How long have you owned this horse?

What discipline(s) have you done with this horse?

What is the experience level of riders this horse is used to?

What was the horse's career prior to your ownership

How often in the last 6 months has this horse been ridden?

Temperament/Behavior

How does your horse do with the following?

	Great	Neutral	Bad	Not Sure
Around Children
Ground Manners
In pasture with other horses
In pasture without other horses
While being groomed
In-hand leading
In a stall
In crossties
Catch (easy to catch in pasture)
Picks up feet
Leads from both sides
Trots
Respects leader's space
Responds to vocal cues
Mount
Dismount
Moves forward willingly
Responds to leg cues
Responds to halter in lieu of bridle
Accepts off-balance movement of rider
Accepts a rider moving forward, backward, sideways, etc
Canters
Knows canter leads
Loads into a trailer alone
Loads into a trailer with a buddy

If a mare, what is the behavior like when in season?

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Final Questions

Why are you interested in having your horse join Free Rein Therapeutic Riding?

How did you hear about us?

Anything else you would like to share about your horse?

	Yes	No
Nerved
Laminitis and/or founder
Navicular changes
Other hoof problems: ringbone, quarter cracks, etc...
History of hoof abscesses

English Saddle	Western Saddle	Bareback Pad
Bareback - no pad	Snaffle Bit	Curb Bit
Tom Thumb Bit	Hackamore - Mechanical	Hackamore - Non Mechanical
Driving Harness	Long Lining	Lunge Lining

Cribbing	Weaving	Stall kicking	Wood chewing
Nippy/bites	Antsy when tied	Herd-bound	None
Other, please specify below