Equine Profile

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*Please read the following DISCLAIMER before filling out your profile

Please complete each section in order to best assess what program we can recommend to you. All information will be maintained as strictly confidential.

Please ensure that all marked areas are filled out before submitting.

Personal Profile

*Name/Owner:

Does your horse get regular exercise?

*Last Name:

*Address 1:

Please list any other conditions:

Address 2:

*City:

*Province/State:

Please list all current pharmaceutical drugs:

*Country:

*Postal/Zip Code:

*Telephone 1:

Please list all current vitamins, herbs, or food supplements:

Telephone 2:

Fax:

*E-mail:

What are your areas of concern regarding the health & performance of your horse?:

Name of Horse:

Breed:

Date Of Birth:

Veterinarian:

Date of Last Visit:

Reason For Visit:

Horse Health Profile

Instructions: Answer the statements below by checking the line which applies to the animal.

Experiencing decreased performance
Bleeding from nose after exercise
Congestion in sinuses and lungs, allergies, heaves
Breathe polluted air and or ammonia
Constipation and or hard stools, flatulence
Feelings of depression, lack of spirit
Easily agitated, washed out
Exposed to pesticides and chemicals
Kidney/bladder problems
Stomach ulcers or abdominal pain/colic
Breeding problems/infertility
Lameness
Over weight/underweight
Pregnant or nursing
Chronic bacterial or fungus infections

No representations are made regarding compliance with all Racing Corporation regulations. Direct questions regarding food supplement ingredients, consumption times and animal health to your veterinarian..

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