Genesee Valley Equine Clinic | Gastroscope History Form

Owner Name *

First

Last

Horse's Name *

Horse's Age (in years) *

Horse's Sex *

Female/Mare
Male/Gelding
Male/Stallion

Horse's Breed *

Where does your horse live? *

What discipline(s) is your horse used for? *

Is the horse in active training? *

Yes
No

If yes, what is the training workload?

Light
Moderate
Heavy

How often is the horse ridden or worked per week?

Housing (Check all that apply) *

How many hours per day is the horse stalled? *

How many hours per day is the horse turned out? *

Is hay available during turnout? *

Is the horse fed a grain or concentrate? If so, how many feedings per day? *

If the horse is fed a grain or concentrate, how many pounds are they fed per feeding?

If fed, what is the brand of grain or concentrate that is fed?

What type of hay/roughage is fed to the horse? (Check all that apply). *

If you answered "grass" to the question above, what type of grass hay is fed?

If you answered "other" to the question above, what type of hay/roughage is fed?

What supplements is the horse fed? Please include brand name and frequency. *

What medications is the horse on? Please include name, concentration, and frequency. *

Recent Stressful Event - Has the horse participated in a single-day competition? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

Recent Stressful Event - Has the horse participated in a multi-day competition? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

Recent Stressful Event - Has the horse been trailered for less than 4 hours? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

Recent Stressful Event - Has the horse been trailered for more than 4 hours? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

Recent Stressful Event - Has the horse had an increase in workload or training? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

Recent Stressful Event - Has the horse moved to a new location or started working with a new trainer? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

Recent Stressful Event - Has the horse experienced a change in their herd dynamics? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

Recent Stressful Event - Has the horse experienced another stressful event, such as illness, layup, or injury? *

Yes, within the last 2 weeks.
Yes, within the last 2-4 weeks.
Yes, within the last 4-8 weeks.
Yes, greater than 8 weeks ago.
Never or not in the recent past.

If you answered yes to the previous question re: other stressful events, which event occurred? (Check all that apply.)

Do you suspect the horse has ulcers? *

Yes
No
Maybe

If you feel the horse may have ulcers, why? (Check all that apply.)

If the horse has a recent history of colic, please provide the date of last occurrence, severity, and treatment.

Ulcer History - Has the horse been previously diagnosed with ulcers? *

Yes
No

Ulcer History - If the horse was previously diagnosed with ulcers, when?

Ulcer History - If the horse was previously diagnosed with ulcers, how was the diagnosis made?

Gastroscopy
Presumptive diagnosis
Other

Ulcer History - If the horse was previously diagnosed with ulcers, were the ulcers treated?

Yes
No
I don't know

Ulcer History - If the horse was previously treated for ulcers, how long was the duration of treatment?

Ulcer History - If the horse was previously treated for ulcers, when was the last day of treatment?

Ulcer History - If the horse was previously treated for ulcers, what product was used?

GASTROGARD (omeprazole)
Other

Do you currently use ulcer prevention for this horse? *

Yes
No

If you currently use ulcer prevention for this horse, what product(s) do you use? Please list all here.

If you currently use ulcer prevention for this horse, when was the product last given?

If you currently use ulcert prevention for this horse, how do you use it?

Daily
During stressful situations
Other

When was the last time this horse was dewormed? *

What was this horse last dewormed with? *

Gastroscopy History Form

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