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Trust Technique intake
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Intake form
Home
Treatment
Intake form
1
Step 1
Name
Your name
Postal address
Street + nr
Zipcode
City
Phone
Email
email
How did you find Joey Philips?
Google
Facebook
Other
If other:
Details of your horse
Stable address
Street + nr
Zipcode
City
Horse's name
Age
Breed
Sex
Stallion
Gelding
Mare
In foal
Currently with foal
Previously in foal
Medical data
Last vet visit
date_range
Reason
Vaccinations
What vaccinations? And when was the last?
0
/
Worming
When was the last? Fecal count?
0
/
Last dental visit
date_range
Treatment?
Farrier
Details?
0
/
Nutrition
Roughage
Silage
Hay
Other
Grazing?
Yes
No
Hours
each day
Concentrates?
Yes
No
Details
Please provide brand and quantity per day
0
/
Supplements?
Yes
No
Details
Please provide brand and quantity per day
0
/
Work
What type of exercise, and how many times/hours a week?
0
/
Who is the rider?
Is the horse stabled and if so, how many hours a day?
About the appointment
Why
Why did you make an appointment?
0
/
Issues
Please give detailed description of any issues
0
/
Other therapies
Did you try other therapies? And with what result?
0
/
Trauma
Past trauma?
Yes
No
If yes
What kind of trauma and was it treated?
0
/
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