DATE       [                     ]

                                 HEAD SHAKING QUESTIONNAIRE

Your Name and contact details.         [               ]

Name of horse    [                      ]

Age of horse        [         ]

Sex         [          ]

Breed         [           ]

Discipline           [         ]

Age at onset of head shaking    [              ]

Year of onset               [              ]

Seasonal ( spring summer only)

Year round or other   [               ]  If ‘other’ please give times. [            ]

Any treatments  [                    ]

Responses to treatment [                                      ]

Describe your horses symptoms of ‘head shaking’   

     [                                        ]

PRIOR TRAUMA

Is there any history of a fall or traumatic accident?     [                                    ]

When     [             ]

Any noticeable changes since accident   

(i)  physical ( change in gait, health....etc  [                     ]

or      (ii) behavioural   [                    ]

Any treatment       [                         ]

LAMENESS

Has your horse ever been diagnosed with Laminitis, Pedal osteitis, navicular disease.   [                            ]

Which leg or legs   [                              ]

Is your horse reluctant to trot?    [                       ]

Rushes on landing after a jump           [                            ]

Stiff & short when cold but warms out of this.      [                      ]

        

Gait - short  gait & stumbles occasionally  in front [             ] behind  [     ]

Chronic lameness -  I ‘hoof pain’ or idiopathic ( of unknown origin)

             [                   ]        other    [                  ]

Is the  lameness worse at shows ‘ events or when excited?

Shortened gait in front        [               ]

                         behind             [             ]

WHEN RIDDEN -

Stiff to the left   [                     ] right  [            ]

Reluctance to ‘collect’ or ‘round up’    [                 ]

any other comments when ridden    [              ]

SHOEING -

Difficult to shoe 

in front ( sensitive when nails driven in.. or lame after shoeing for a few days.)

behind. - resistant to having leg stretched out behind.

FEET -

          - Healthy ( good growth & strength)        [                 ]

            Poor - ( poor nail holding / crumbling / poor growth)  [              ]

            Poor heal growth or excessive wear -     [                    ]

            Other comments        [                               ]

         - Normal pulse and temp       [                   ]

         - Increased pulse                   [                   ]

         - cold feet ( at coronet)           [                   ]

         - hot feet ( at coronet)             [                  ]

SWEATING -

sweats normally              [                   ]

sweats profusely             [                    ]

sweats mostly neck & shoulders only   [                    ]

doesn’t sweat (non sweating syndrome.)                  [                     ]

Coat

how would you grade your horses coat ?

Excellent - rich colour and shine ( oily)    [                  ]

Good to fair - nearly above   [                     ] 

Poor - dry and poor colour      [                     ]

other    [              ]

If less than excellent are there areas of good (rump) and poor ( chest or neck) etc.?

BEHAVIOUR :-

Would you describe your horse as a little ‘Jeckyl & Hyde’ .i.e. soft and cuddly under an often unpredictable exterior  [                    ]

explain      [            ]

Head or bridle shy!    [             ]

Oversensitive to flys [                   ]

Resents grooming?   [                      ]

Resents mane pulling [                     ]

Girthy or ‘girth sensitive’  [                  ]

Cold backed / sensitive under saddle  [                    ]

Resents narrow spaces . e.g. rushes through doors, difficult to load onto trailer   [                  ]

Bucks early when ridden  [                   ]

BEHAVIOURAL SELF MUTILATION

Biting at tendons joints flanks...     [                       ]

kicking or striking at muzzle or belly     [                       ]

ANTISOCIAL-

keeps away from other horses, aggressive towards other horses, doesn’t mix in the herd ( stays on perimeter of herd).  [                      ]

TRAVELLING - Van , Trailer, float,

good traveller           [                ]

poor traveller   Describe - e.g.  Rocks /  scrambles / ‘sweats up’

    [                ]

TEMPERATURE SENSITIVE

always keeping out of sun  [               ]

putting muzzle in drinking water  [           ]

CHIROPRACTIC  Acupuncture, touch therapies, massage , homeopathy .western medicine..... etc.    Has your horse had any form of treatment for any of the above anomalies ?               [               ]

Which type of therapy   [                ]

results of treatment [                    ]

results were , permanent [                  ] Temporary [                   ]

If temporary for how long [                       ]

ANY OTHER COMMENTS

   [                                           ]