Glastonbury CT Vet

Equine Check-In Form

Please fill out the following information to help us better identify area of concern.

Client

Patient

Breed

Sex

Age

 

What does your animal eat? (please include brand, type of hay & amount given)
   

Does your animal get any nutritional supplements or additives? (please list)
 
  

Does your animal receive any medications on a regular basis? (please list)


 

Does your animal have any of the following warning signs? CHECK all that apply.

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Change in appetite (increased or decreased)

Abnormal gait / lameness

Change in drinking (increased or decreased)

Unwilling to go forward under saddle

Difficulty chewing, dropping of feed while eating

Frequently trips when under saddle or while in hand

Demonstrates signs of discomfort 10-20 minutes after a grain meal

Demonstrates signs of discomfort when being saddled or groomed

Odor from mouth or nostrils

Difficulty with leads at canter

Unintentional weight loss or weight gain

Hives or other lesions on the skin

Changes in urination or defication (frequency / volume / consistancy of stools)

Changes in attitude, behavior or "spookiness"

Nasal discharge

Decreased stamina / exercise intolerance

Cough

Increased respiratory noise when at work

Ocular discharge or increased tearing

Other signs

Increased respiratory rate / effort when at rest

 

 

Do we have your permission to use a picture of your pet for our marketing campaigns? Yes     No

 

Please be sure to fill out as much information as possible before sending.