Equine Sports Medicine and Rehabilitation Patient History Form

Patient history form

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This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Email(Required)

Horse's name(Required)

Please describe your horse's presenting complaint for the appointment.(Required)

List specific concerns, symptoms, and/or behaviors to be addressed by our team.

Has your horse been evaluated by CSU Equine Sports Medicine or any other CSU veterinary service before?(Required)

Yes

How has your horse been doing since the last visit?(Required)

Please provide a brief overview of your horse’s veterinary history outside of CSU.(Required)

Include lameness, diagnostic imaging, joint injections, and/or surgeries with approximate dates.

Please provide a brief overview of your horse’s veterinary history.(Required)

Include lameness history, joint injections (with approximate dates), diagnostic imaging, etc.

Is your horse on any current medications and/or supplements?(Required)

Yes

List of medications/supplements(Required)

Only list what you are currently giving. Example: Equioxx, 57mg, once daily. Click the plus icon (+) on the right to add a row.

Name of medication or supplement

Dose

Frequency of administration

What is your primary goal for this appointment?(Required)

Is there anything else you would like us to know about your horse?

Were you referred to CSU by your veterinarian?(Required)

Yes

Veterinarian's name(Required)

First Last

Additional questions? Contact us at (970) 556-3931 or [email protected]

If you haven’t already, please email us pertinent patient records (including X-rays).