Horse Training and Work Information
Previous training and work: _______________________________________
Current Training and work: ________________________________________
Intended Use: __________________________________________________
Any showing history: _____________________________________________
Is re-sale a consideration?: ____________________________________
Some owner’s are willing to share the following information more than others, any available history will help with the final assessment.
Medical History - any lameness history? Does horse receive any joint injections for treatments or maintenance? if so, please include any information below and when last treated:
Medical History - any non-lameness related medical history i.e. respiratory issues, colic, ulcers?: _____________________________________________________________________
Coggins - when was this last done?: ________________________ Vaccines - indicate if done: Flu/Rhino_____ PHF ________
EWT_________ WNV _______
Rabies _______ Strangles _____ Lyme ________
If this is a mare, any breeding history, any foals? _____________________________________
Any information on heats and behavior? Is Regumate used? ____________________________
Are there any other issues you would like considered? i.e. gait irregularities, lead issues, swelling or sensitivities? Any respiratory noises? i.e. coughing, increased noises. GI issues?
As part of the exam this horse will be evaluated with an extensive physical exam, observation of movement at all three gaits, with a rider if available or requested, and with flexion tests. Radiographs can be taken based on the results of the exam or, if desired, a package can be put together of regions commonly evaluated. If you have certain radiographs in mind they can be taken as well and options are listed below.
Radiographs - Deciding on whether to radiograph or not and where can be made prior to the exam or after. Below is a list of options if you have certain regions you already know you will want x-rayed, please check any that apply:
Front Feet - Navicular _____
Front Fetlocks _____
Knees _____
Hind Fetlocks _____
Hocks _____
Stifles _____
Back - DSP (for Kissing Spine) _____
Neck (cervical vertebrae) _____
Will decide based on the exam results: ___________________________________________
List any radiographs or regions you are interested in: ________________________________
An ultrasound evaluation is another option to consider and may be appropriate if swelling or thickness is found with the limbs and can be decided on after the exam. If you know this is something you are interested in, please indicate what you would like evaluated: ___________
Is scoping or endoscopy of the upper airway desired? May be used to evaluate respiratory issues i.e. roaring. This too, can be decided on after the exam ________________________
Laboratory Tests
In this section you will have the option of choosing laboratory tests. If there are some not listed or you would like done, please contact us or enter below.
PPE Drug Screen - blood will be drawn and held at no charge for 60 days and can be submitted later if desired. If you definitely want the test to be run then please indicate that here: Submit test: _________ Hold blood and do not submit at this time: ________
CBC - evaluate for anemia and general health status ____________
Chemistry - evaluate for profiles on protein levels, electrolytes, liver and kidney ___________
Coggins Test - ________________________ (recommended within 60 days of sale)
Lyme Test - __________________
EPM Test - __________________
Vitamin E level - ______________
Any other tests you are considering? _
PPE reporting: If you are present all results will be discussed at the time of the exam or if not there contact can be made by phone to discuss exam during and after. If you will not be present be sure to list a phone number for this purpose: __________________________
A written report will follow to summarize all findings and can be emailed to you, please include your email address: ____________________________________________________
If you have a Veterinarian you are consulting with and would like information sent or discussed with that person, please list name, phone and email address:
Payment options for the evaluation If you are a regular client of Burlington Equine, billing can happen through the office later, if not, we request having credit card information on file or agreeing to pay by check at conclusion of exam.
Credit Card: ____________________________________________________________
(If preferred this can also be called into the office ahead of the exam date)
Check ________
Once completed the form can be emailed or faxed back to Burlington Equine:
Email: bevet@gmavt.net
Fax: 802-425-5353
Any questions, please call 802-425-5454 or call.
