Returning Patient Form

EQUINE CLINICAL SERVICES
University of Minnesota College of Veterinary Medicine

PRE-ADMISSION FORM RETURNING PATIENT

Welcome back to Equine Clinical Services Please complete the information requested and return the form electronically ("Submit at the bottom of the form) or fax (612-625-9796) to the Equine Hospital before your scheduled appointment. If you have not been a client within the past 5 years, please complete the “New Client” form. If you cannot return the form before your appointment, please bring the completed form with you. (Click HERE for a printable form) A helpful check list is provided. Thank you and we look forward to your visit!

CLIENT NAME:

A) Primary Patient Information

Names: Stable Name Registered Name
Horse	Birth date: or age:
	Sex	Mare/Filly	Female spayed
		Stallion/Colt	Gelding
Description:	Color and Markings
	Height hands inches
Activity Description What type of activity has your horse performed in the past 6 months? What are your goals for your horse?
Insurance information Please bring your insurance information including the contact information for your agent with you to your appointment. Is your horse insured for any of the following?
Health	Major Medical	Surgery	Mortality

B. Accompanying Animals

If you are bringing any additional animals to accompany your horse ( mare with foal, companion horse, goat, etc.), please provide the following information about the accompanying animal.

Animal's Name: Stable Name
Species Breed
Birth Date or Age

Sex Female intact Female spayed

Male intact Male castrated
Relationship to Patient

II. Patient Health Information

A) Current Reason for Admission

Please briefly describe the reason for your horse’s admission:
If you have you been given a tentative diagnosis or reason for the problem by your veterinarian or veterinarians please list/describe below.
When was the problem first observed?
hours ago days ago weeks ago

months ago years ago Not applicable
If the onset was associated with a specific event (injury, change in feed or management please describe the event and what the problem looked like when it initially appeared.
If the problem is related to a limb or limbs, please describe the regions that appear to be involved:
Has your horse received any treatment (including rest or a change in housing) for the problem?
Yes ¿ Please bring records of all treatments and bring (or request that your veterinarian send) any radiographs, blood work, or other laboratory test results available.
No - If checked, skip to question 18.
Not applicable ¿ If checked, skip to question 18.

Please indicate what treatments (Tx) the horse has received, who initiated the treatment (specific veterinarian, trainer, therapist, farrier, owner, etc), and how the horse responded from oldest to most recent in the table below. If multiple treatments were initiated and ended at the same time, include them in same line:

Date	Individual recommending or performing Tx	Treatments (as specific as possible, including doses if known)	Tx Duration	Response

Did your horse have any of the following assessments? (bring the results of these tests with you)

Radiographs/Ultrasound/CT/MRI: Yes No

Lab Work: Yes No

Nerve Blocks Yes No
At the time of completion of this form, how does your horse¿s problem compare to the time it was originally noticed?
No change ¿ If checked, please skip to question 19.
Improved ¿ If checked, please skip to question 18.
Original problem is worse ¿ If checked, please skip to question 18.
Please describe how the original problem has changed

B) Additional Problems for Evaluation

Please describe any additional concerns that you would like to discuss or have evaluated while at the College and indicate if you are interested in a full evaluation or an initial consultation. If none, please skip. If your horse has any additional problems or health concerns that you would like to have evaluated, we would be happy to assist you. We have specialists who work closely with referring veterinarians. We will arrange to have a specialist in the appropriate area available to talk with you (before or during your visit) and, if requested, evaluate your horse while you are here. This also will allow us to plan for adequate time if additional evaluation is requested.

Concern Description Initial consultation Evaluation

C) General Health Information

Vaccination History - Please provide the date of the most recent vaccination of your horse for the following:
None given within last year
Vaccines given within last year but not sure which ones
Vaccines given on the following date but not sure which ones - Date The following vaccines were given on the date shown (month/year is adequate).

Tetanus toxoid (standard booster)	Tetanus antitoxin	EHV1
EHV4	EEE/WEE/VEE	EPM
Influenza	Leptospirosis	Lyme
Potomac Horse Fever	Rabies	Rotavirus
Strangles	West Nile
Other

Feed/Nutrition Please following feeds that you provide to your horse on a daily basis.

Pasture hrs/day, Pasture type Quality
Hay lbs/day or flakes/day ad lib
Hay access daily; Hay type Quality
Grain lbs/feeding; feedings/day Grain type
Supplements: Salt source
Mineral source

Water Source: Type of water Hours/day available

Housing
Please indicate the number of hours/day that your horse is in each of the following settings. If you do not use a type of housing, you may leave it blank or put in zero.

Stall	Small Padock/ring
Dry or sand lot	Pasture

Exercise
Please indicate the average number of days/week that your horse receives each of the following:

Stall rest only days/wk	Hand walking only days/wk
Small paddock/ring days/wk	Pasture days/wk
Lunging days/wk
Light riding (< 60 minutes, primarily walk/trot) days/wk
Moderate riding/work: days/wk
Intensive riding/work (Maximal work for the breed/activity) days/wk

If the lameness is only or best observed while the horse is ridden, it may be useful for us to see the horse work under saddle. Please indicate if you will be bringing tack with you:
Yes No

CHECK LIST OF THINGS TO BRING TO YOUR APPOINTMENT:

A copy of your pre-admission forms
Insurance policies and agent contact information
Records from referring or primary veterinarians
Copies of previous diagnostic images (photographs, radiographs, ultrasound images, videos, scans) from other veterinarians
Copies of previous laboratory (blood, biopsy, cytology) work
Details on feeding, vaccination, and deworming programs

Thank you for completing the Pre-Admission Client Information. Please also complete the appropriate form for your horse (New Patient or Returning Patient) and submit both forms electronically if possible, or bring them with you to your appointment.