Equine Recheck Form Owner and Horse Information LAST NAME * FIRST NAME * HORSE'S NAME * ADDITIONAL OWNER'S NAMES ON THE HORSE'S FILE ADDRESS LINE 1 * ADDRESS LINE 2 CITY/TOWN * POSTAL CODE * PROVINCE * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon PHONE NUMBER * (###) ### #### History HOW HAS YOU HORSE BEEN SINCE THE LAST VISIT? * CURRENT ITCH LEVEL (rate on a scale of 0-10) 0 = Not Itchy, 1-2 = Very Mild Itch, 3-4 = Mild Itch (more frequent), 5-6 = Moderate Itch (regular episodes), 7-8 = Severe Itch (prolonged), 9-10 = Extremely Itchy (continuous, unable to rest). ANY SKIN LESIONS? * YES NO IF YES, WHERE ARE THE LESIONS LOCATED ANY RESPIRAITORY ISSUES? * YES NO IF YES, PLEASE PROVIDE BRIEF DESCRIPTION IS YOUR HORSE RECEIVING IMMUNOTHERAPY (ALLERGY SERUM)? * YES NO IF YES, LIST HOW MUCH AND HOW OFTEN Please note if on Oral or Injectable Immunotherapy IS YOUR HORSE RECEIVING ANY MEDICATIONS? * YES NO IF YES, PLEASE LIST CURRENT MEDICATIONS Please list what medications your horse is receiving, how much and how often they are given DO YOU USE FLY SPRAY * YES NO IF YES, LIST WHICH ONE Diet CURRENT FEED * CURRENT TREATS CURRENT SUPPLEMENTS Additional Information WHICH SEASON IS YOUR HORSE MOST AFFECTED? * Spring Summer Autumn Winter Year Round ARE THERE OTHER ANIMALS AT THE BARN WHERE YOUR HORSE IS HOUSED? * Select all the apply Cat Dog Goat/Sheep Cow Chicken Other (please specify below) None HAVE YOUR HORSE'S SYMPTOMS IMPROVED OR WORSENED? * ANY OTHER INFORMATION YOU FEEL IS IMPORTANT FOR US TO KNOW? Thank you, we have received your recheck form.
