Alternative Practitioner Thomas Meffert

Praxis for Dorn-Therapy for humans and horses

Medical history form for horses

Please fill out this medical history form before your first appointmentdirectly on your PCand send this back perE-Mail to me in due time.Iprint the case history form, so thatyou can sign it on the last page at your first appointment.Please understand, that the full treatment fee hast o be paid when the appointment hasn`t been cancelled two days in advance.I cannot use hand written resp: scanned medical history forms.

Important information: A great deal of the therapytakes place during movement. For this a riding hall, riding area or paddock is necessary.Your horse should be able to move backwards. The therapy takes ca: 3 hours including static and dynamic analysis.Therefore, please take adequate time, this means plan the booking of the riding hall. Parallel riding in the riding hall is not a problem for the therapy as far as I´m concerned. For the detailed procedure of the therapy, see homepage:

Should you have any questions please contact me beforehand.

Contact data

Vorname, Surname
Private address
Street, House Number
Post code, City
Stable address
Street, House Number
Post code ,City
Mobile number
Land line
E-Mail

Basic data horse

Name
Breed
Age
Gender
Owner since

Dental Treatment

Name of your dentist
Nr: of treatments per year
Are there any teeth or jaw problems?

Hoof Handling

Does the horse have shoes, if sowhere? (front back, complete)
With shoes: What is the reason for this?
With bare hooves: Who is the blacksmith?
With bare hooves: Adaption technique (DIFHO, DHG, Schmied, …) ?

Vetinary medicine / Alternative medicine

Name of the Therapist
Are there any previous illnesses, if so, which? wenwelche?

Feeding

Do you feed anything apart from hay and straw, was? anderes?
If yes please fill out the following table
Animal feed / Amount per day / Why do you give this feed?

Animal Housing

Describe how you keep your horse: Open stable Box, Paddockbox, free stall
If Box: How many hours per day does the horse stand in the box?

Work

Type of riding (Englisch, Western, …)
Equestrian disciplines(Dressur, Springen, Distanz, …)
Does your horse take part in tournaments?
How often do you let your horse run free?
Does your horse go into a leading arena, Whenyes, how often and why?
Do you use a bearing rein, when yes, why?
Do you longe, when yes, how often and why?
Do you do ground exercises, when yes, which technique? (z.B.: Parelli, TT,)
Which people ride your horse?Please fill out the table below ( Don`t forget yourself )
At what age was your horse broken in?
Rider / Rides x times / Qualification (e.g. Riding teacher)
Per week / Perunit

Saddle

Do you normally have problems with the saddle fit?
When was your last saddle fitting?
Do you use different lengths of stirrups?

General characteristics of your horse

Describe your horse`scharacter.
Does your horse have any special characteristics?
Does your horse kick, if so, when?
Does your horse mount, if so when?
Does your horse buck, if so, when?
Are there any problems concerning dominance?
Can your horse go backwards? (Important info for the therapy)

Vorbehandlungen im Bewegungsapparat

Type of therapy(e.g..Chiropractic) / Date / Therapy

Does anyone who rides your horse have problems with their own musculosketal system, if so, which? (Belonging to this e.g.: Pelvic obliquity, back ache, Knee pain, wrist problems, Problems to ride with the left or right hand , headache, insoles in the shoes, ….)

Is there any information regarding your horse`s past (ancestry, previous owner)?

Describe the horse`s current problems in more detail here.

What are your wishes regarding my therapy?

Diagnostic findings: Please get all of the medical findings, includingx-rays, CT, MRT, etc. if possible before your first appointment.

Information:

  • Basically every therapy can involve a risk (Example: Chiropractic, osteopathy, Acupuncture, Dorn-Therapy,)
  • Basically I work with very targeted and low risk techniques and undergo continual further education. Consequently the risk is reduced to an absolute minimum.
  • Basically the respective risk factors will be image guided resp: further medical statements consulted to uncover possible risks.
  • With help of the medical history forms and the following examination, possible risk factors can be found..
  • If anything is unclear, please ask me, I assume your approval.

I have read and understood questionnaire fully and filled it out to the best of my knowledge.

(The signature will be signed at your first appointment)

Date …………………………………. Signature…………………………………………………..

(With minors) Name of the legal guardian: ………………………………………………………