Gastroscopy Exam Intake Form Date:Examining Veterinarian:Horse Name:Owner Name:Age:Breed:Gender:Where is the horse stabledWhat disciplines is the horse used for?In Active Training?YesNoIf yes, training workload?LightModerateHeavyHousing (Circle all that apply): Stall Paddock Pasture alone Pasture with others Dry lot with others Hay during turnout Hours/day in stall:Hours/day turnout:Diet: Grain/concentrate feedings/day:1X2X3X4 or moreGrain type/brand:Pounds/feeding:Type of Hay (Circle): Alfalfa Grass Mixed Other: SpecifyForm of Hay (Circle): Flakes Cubes Pellets Other: SpecifySupplements and frequency (current):Medications and frequency (in last 4 weeks):Recent Stressful Event HistoryWhen exposed Competition-single day: less than 2 weeks 2-4 wks 4-8 wks +8wks never Competition-multi-day: less than 2 weeks 2-4 wks 4-8 wks +8wks never Trailered-less than 4 hours: less than 2 weeks 2-4 wks 4-8 wks +8wks never Trailered-more than 4hrs: less than 2 weeks 2-4 wks 4-8 wks +8wks never Increased work/training: less than 2 weeks 2-4 wks 4-8 wks +8wks never New barn or trainer: less than 2 weeks 2-4 wks 4-8 wks +8wks never Change in herd dynamics: less than 2 weeks 2-4 wks 4-8 wks +8wks never Change in feed: less than 2 weeks 2-4 wks 4-8 wks +8wks never Other (illness/layup/injury): less than 2 weeks 2-4 wks 4-8 wks +8wks never (Circle) Colic eye disease respiratory disease lameness other SpecifyDo you suspect this horse has ulcers?YesNoIf yes, why? (circle all) Decreased Performance Unwilling to work Girthy Bad attitude/crabby Off Feed Picky Eater Not gaining weight Poor Coat Quality Weight Loss Other: SpecifyColic:MildModerateSevere# Times:Date Last Colic:SpecifySpecifyUlcer History:Previously Diagnosed with ulcers?YesNoIf yes, when?How diagnosed?GastroscopyPresumptiveOther:SpecifyWere the ulcers treated?YesNoSpecifyDuration of treatment:Date of last treatment:Do you use ulcer preventative?YesNoIf yes, what product?Date last used?How used?ContinuouslyDuring stressOtherSpecifyWhen was horse last dewormed?Product used?Gastroscopy FindingsTempPulseRespSedation used:Other treatmentsExam Findings:Treatment recommendations:Follow up Recommendations:Signature
