Shivers Research Survey

1. BASIC INFORMATION

	MM		DD		YYYY
Enter date:	BASIC INFORMATION Enter date: Month	/	Day	/	Year

2. Please enter the following horse owner information:

Please enter the following horse owner information: Name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Country:
Email Address:
Phone Number:

3. Veterinarian Information:

Veterinarian Information: Veterinarian's Name:
Veterinarian's Phone Number:

4. Horse Information:

Horse Information: Horse's Registered Name:
Horse's Nickname:
Horse's Year of Birth:
Horse's Height:

5. Horses' Gender:

Horses' Gender: Female, Intact

Female, Spayed

Male, Intact

Male, Castrated

6. Basic Information

	What is Horse's Breed:	Horse's Current Body Condition:	What is Horse mainly used for:	How much time does horse spend in stall, per day:
For Horse:	Basic Information For Horse: What is Horse's Breed:	Horse's Current Body Condition:	What is Horse mainly used for:	How much time does horse spend in stall, per day:

If Other breed, please enter here

7. Was horse imported from another country?

Was horse imported from another country? Yes

No

If yes, from which country?

8. Is Horse Alive?

Is Horse Alive?

9. If NO, how did horse die?

If NO, how did horse die?

If other, please describe here

Shivers Research
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