Equine Massage Evaluation Form
Please complete this form to document the horse's condition and observations before and after massage therapy.
Owner's Full Name
*
First Name
Last Name
Owner's Email Address
example@example.com
Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Horse Information
Please provide details about the horse.
Horse's Name
*
Horse's Age
Breed
Sex
Mare
Gelding
Stallion
Other
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presenting Problems or Concerns
*
Assessment of Muscle Groups (Rate tension/discomfort)
*
Rows
Neck
Shoulders
Back
Hindquarters
Legs
None
1
2
3
4
5
Mild
6
7
8
9
10
Moderate
11
12
13
14
15
Severe
16
17
18
19
20
Behavioral Observations Before Massage (select all that apply)
Restless
Sensitive to touch
Lethargic
Tense muscles
Other
Behavioral Observations After Massage (select all that apply)
Relaxed
Improved movement
Reduced sensitivity
No change
Other
Overall Response to Massage
1
2
3
4
5
Recommendations / Follow-up
Signature of Owner/Authorized Person
*
Submit Evaluation
Submit Evaluation
Should be Empty: