Book Bodywork for Horse or Rider

Equine Health Intake Form

Owner Information

Owner's Name

First Name

Last Name

Phone Number

(###)

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####

Emergency Contact Name

Emergency Contact Phone Number

(###)

###

####

Referred by

Horse Information

Horse's Name

Breed

Age

Sex

Color/Markings

Disciplines/Primary Use

Current Exercise/Training

Veterinarian Name

First Name

Last Name

Veterinarian Phone Number

(###)

###

####

Location of Horse

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

General Health & Medical History

Has your horse ever had any known medical history such as the following: medical conditions, any major injuries, neurological issues, lameness, prone to tying up, or currently on any medications

Internal & Systemic Health

Has your horse ever had any internal or systemic health concerns such as respiratory problems (e.g., heaves), colic episodes, digestive problems, skin conditions, or allergies?

Current Care & Sensitivities

Has your horse had any recent changes in diet or routine?

Is your horse currently receiving any other therapies (e.g., chiropractic, acupuncture, farrier)?

Is your horse sensitive to touch in any areas?

Is your horse difficult to handle in any way?

Current Concerns/Goals for Massage & Bodywork

Please describe any specific areas of concern or goals you have for your horse regarding massage and bodywork

Consent & Release

I, the undersigned owner, hereby grant permission for Kimberly Eckhart of KinEquis, LLC to perform massage and bodywork on my horse. I understand that this work is not a substitute for veterinary care. I have provided all known relevant health information and will inform the practitioner of any changes in my horse's health status. I understand that the practitioner is not a veterinarian and cannot diagnose or treat medical conditions. I have read and agree to the cancellation policy and disclaimers.

Photo and Video Consent

I grant KinEquis permission to take photos and/or videos of my horse, during sessions for use in future marketing materials. This may include sharing on social media, your business website, and in educational content. I understand that my horse's identity will be kept anonymous unless I give specific permission to use their name.

Yes, you may use photos/videos of my horse.

No, please do not take or use photos/videos of my horse for marketing purposes.

Signature

For your first session, please complete this form thoroughly to ensure the best possible care for your horse during massage and bodywork sessions. All information will be kept confidential. We will reach out to schedule an appointment for your session. For returning clients, please reach out directly at 503-498-8301 or contact@kinequis.com to get scheduled, an additional intake form is not necessary.

Cancellation policy and disclaimers.

Massage and Bodywork Health Intake Form

Please complete this form thoroughly to ensure the safest and most effective massage and bodywork session. All information provided will be kept strictly confidential. We will reach out to schedule an appointment for your session. For returning clients, please reach out directly at 503-498-8301 or contact@kinequis.com to get scheduled, an additional intake form is not necessary.

Personal Information

Name

First Name

Last Name

Date of Birth

YYYY

Phone Number

(###)

###

####

Email Address

Emergency Contact Name

Emergency Contact Phone Number

(###)

###

####

Referred by

Health History

General Health & Medical History

Are you currently taking any medications?

Do you have any allergies? (medications, environmental, lotions, oils)

Have you had any recent surgeries (within the last 6 months)

Do you have any chronic pain or fatigue

Cardiovascular/Circulatory Health

Do you have any history of cardiovascular or circulatory concerns such as the following: high blood pressure, low blood pressure, heart conditions (arrhythmia, heart attack, bypass surgery, etc.), pacemaker, blood clots, varicose veins, swelling/edema or bruising easily?

Musculoskeletal Health

Do you have any history of musculoskeletal concerns such as the following: arthritis, osteoporosis, fibromyalgia, joint replacements, sprains/strains, fractures, sciatica, disc issues (herniated, bulging, degenerative, etc.), muscle weakness, or restricted range of motion?

Neurological Health

Do you have any history of neurological concerns such as the following: epilepsy/seizures, stroke, neuropathy, multiple sclerosis, Parkinson’s disease, headaches/migraines, dizziness/vertigo, or numbness/tingling?

Digestive Health

Do you have any history of digestive concerns such as the following: Digestive disorders (IBS, Chron’s disease), or acid reflux/heartburn?

Respiratory Health

Do you have any history of respiratory concerns such as the following: Asthma, bronchitis, or emphysema?

Skin Health

Do you have any history or current skin concerns such as the following: Eczema, psoriasis, rashes, open wounds/sores, or contagious skin conditions?

Other Conditions

Do you have any history of other conditions such as the following: Diabetes, Cancer (current or in remission), thyroid issues, kidney issues, liver issues, autoimmune disorders, or pregnancy/postpartum (if applicable please specify trimester)?

Current Care & Sensitivities

Are you currently receiving any other therapies (e.g., chiropractic, acupuncture, physical therapy, other)?

Are you currently under the care of a physician?

Lifestyle Information

Stress Level (1-10, 10 being highest)

Physical Activity Level

Exercise Routine

Sleep Quality

Massage and Bodywork Goals

Which session length would you like to book?

What are your primary goals for receiving massage/bodywork today?

Are there any specific areas of your body you would like me to focus on or avoid?

What type of pressure do you prefer?

Is there anything else I should know about your health or preferences that might affect your session?

Consent and Release

I understand that massage and bodywork are not substitutes for medical examination or diagnosis and that it is recommended that I see a primary health care provider for any physical or mental ailment I may have. I affirm that the information I have provided on this form is accurate and complete to the best of my knowledge. I understand that I am responsible for informing my therapist of any changes in my health or medical conditions. I have read and agree to the cancellation policy and disclaimers.

Signature

Date

YYYY

Cancellation policy and disclaimers.