New Patient Form, University of Minnesota Equine Clinical Services

EQUINE CLINICAL SERVICES
University of Minnesota College of Veterinary Medicine

PRE-ADMISSION FORM NEW PATIENT

Welcome to the Equine Clinical Services of the University of Minnesota College of Veterinary Medicine.  In order to facilitate the admission process, we ask that you complete as much of the information requested below as possible.  Please 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 possible.  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:

PATIENT INFORMATION

I. Patient Background Information

  1. Names:
    Stable Name Registered Name
  1. Horse
 Birth date: or age:
  Sex Mare/Filly Female spayed
    Stallion/Colt Gelding
  1. Description:
 Color and Markings
  Height hands inches
  1. Activity Description
    What type of activity has your horse performed in the past 6 months?

    What are your goals for your horse?
  1. 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.
  1. Animal's Name: Stable Name
  2. Species     Breed
    Birth Date or Age
    Sex Female intact Female spayed
      Male intact Male castrated
  3. Relationship to Patient

    4. II.  Patient Health Information

    A)  Current Reason for Admission

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

    months ago   years ago   Not applicable
  7. 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.
  8. If the problem is related to a limb or limbs, please describe the regions that appear to be involved:
  9. 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.
  10. 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:
    DateIndividual recommending or performing Tx Treatments (as specific as possible, including doses if known) Tx Duration Response
  11. 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 BlocksYes No
  12. 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.
  13. 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.

  1. Concern Description Initial consultation Evaluation

C)  General Health Information

  1. 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


  2. Feed/Nutrition Please following feeds that you provide to your horse on a daily basis.
    1. Pasture  hrs/day, Pasture type Quality
    2. Hay lbs/day or flakes/day ad lib
      Hay access daily; Hay type Quality
    3. Grain lbs/feeding; feedings/day Grain type
    4. Supplements: Salt source
      Mineral source

  3. Water Source: Type of water Hours/day available
  4. 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

  5. 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

  6. 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:

  1. A copy of your pre-admission forms
  2. Insurance policies and agent contact information
  3. Records from referring or primary veterinarians
  4. Copies of previous diagnostic images (photographs, radiographs, ultrasound images, videos, scans) from other veterinarians
  5. Copies of previous laboratory (blood, biopsy, cytology) work
  6. 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.

 

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Last modified on Friday Mar 02, 2007

This page is located at http://www.cvm.umn.edu//eqserv/admissions/New_patient.html