Rider’s Name:
Address:
Contact Phone(s):
How often and for how long do you ride during a typical week?
What type of riding style/showing do you primarily engage in?
What type/breed of horse(s) do you ride?
Do you work with a riding instructor / trainer?
If so, what are you focusing on currently?
What are your current riding goals ?
Do you currently experience pain during or after riding?
After a long schooling session, what areas of your body are most sore?
Have you ever had your saddle fitted to you and your horse?
What would you like to achieve by working with ETS?
Date:
Are you currently experiencing pain? If so, please describe.
Please describe any injuries, surgeries or health concerns that you feel may affect your riding or your ability to participate in a rider fitness program:
In the last six months, have you experienced: (if checked, please explain.)
Chest pain
Headaches
Dizziness or equilibrium problems
Back pain
Pain in your arms, legs or joints
Shortness of breath
High blood pressure
Numbness or tingling
Other:
Are you taking any blood thinners, steroids or heart medications? If so, please list.
What other types of exercise or physical activities do you regularly participate in?
Dr. Jennifer Welter, DPT, CERP, RVT ~ (530) 219-4368 ~ www.EquinePT.com

Sore back
Girthy when saddled
Dislikes grooming
Rearing or bucking or kicking
Biting or striking
Hollowing or lack of engagement
cross canter/disunited canter
Reluctance to go forward
Rushing
Refusing jumps
Poor performance
Difficulty going up or down hills
Difficulty with transitions
Short striding or mincing steps
difficulty picking up or maintaining lead
Difficulty with square halts
Horse refuses to stand still
Difficulty with lateral work
Uneven shoe wear
Pulling or heavy in bridle
Refusal to take contact
Fussy in the bridle
Head shaking or tossing
Teeth grinding
Tail swishing
Horse refuses to stand still while mounted
Tripping, stumbling or loss of balance
Other:
Feel like you are being thrown forward in your saddle
Have a hard time keeping your legs under you
Feel like you are falling off to one side of your horse
Have difficulty keeping your feet in your stirrups/irons
Stirrup leathers stretching unevenly
Instructor is always telling you to bring your legs back
Feel uneven weight in your reins
Have difficulty sitting the trot
Get left behind or get ahead of your horse over fences
Can’t keep your heels down
Have difficulty maintaining consistent rein contact
Ineffective half halts
Other:
Dr. Jennifer Welter, DPT, CERP, RVT ~ (530) 219-4368 ~ www.EquinePT.com

Name:
Age: Sex: Breed(s):
Horse’s Location Address:
What is your horse’s intended or current job?
Describe his current level of training and showing:
Describe any current training issues or difficulties while riding?
Is your horse being treated by your veterinarian for any lameness or other issues? If so, explain problem and any current or past treatments.
Have any diagnostic tests (flexion tests, blocks, Xrays, MRI, CT, ultrasound, etc) been performed?
Is your horse being treated (or has been treated in the past) with any complementary therapies such as chiropractic, acupuncture, massage therapy, laser, PEMF, etc?
General Health History:
Any past history of lameness, injuries or neurologic disease?
Has your horse suffered from colic, ulcers, respiratory problems, allergies, or any other physical problems currently or in the past?
When was your horse’s most recent dental exam and float?
Hoof care:
Farrier:
Most recent trim or shoeing and typical interval
Pads/corrective shoeing?
Problems with interference or pulling shoes?
Does your horse ever get foot sore, develop sole bruises or abscesses?
Is your horse on a regular vaccination and deworming schedule?
Your horse’s diet
Feed amounts and frequency of feeding:
Supplements?
What type of feeder?
Describe your horse’s living environment (stall/pasture/turnout schedule):
What type of saddle, pads and bridle do you ride in?
Have you had your saddle fitted to you and your horse?
Does your horse resent saddling, girth tightening or mounting?
ETS requires a prior veterinary examination and a veterinary referral form to be completed prior to evaluation and treatment of your horse. Performance enhancement and rider treatment are exceptions to this requirement.
Dr. Jennifer Welter, DPT, CERP, RVT ~ (530) 219-4368 ~ www.EquinePT.com