Gastroscopy Preparation Please complete prior to your appointment. If you have multiple horses, please fill out one form per horse. Owner Name * First Name Last Name Horse's Name * Age * Breed * Gender * Mare Gelding Stallion Horse's Location * Reason for gastroscopy? * Is this a repeat gastroscopy? * Yes No If yes, have you noticed an improvement in clinical signs? What discipline is the horse used for? * Is the horse in active training? * Yes No If yes, what is the horses workload? Light (1-2 days per week) Medium (3-4 days per week) Heavy (5+ days per week) Where does the horse live majority of the time? * Box Stall Stall with run Dry Lot Pasture Does the horse receive turn-out time? * No Yes - Under 2 hours a day Yes - Between 3-8 hours a day Yes - More than 8 hours a day Is it a shared turnout? If yes, please list how many horses that your horse shares an area with. If yes, please describe the type of turn out and if the horse gets any meals while turned out. Type of grain/concentrate, brand and amount fed per feeding? * Type of hay fed * Orchard Grass Alfafa Timothy Other (please state at the end of form) Form of hay fed * Flakes Pellets Cubes Supplements the horse is on, with amounts and brand * Medications in the last 4 weeks to today's date * Does your horse have a history of colic? * Yes No If yes, how would you best classify the colic? Mild Moderate Severe Underwent surgery Roughly how many times has your horse coliced in the past year? * Date of last colic? MM DD YYYY * My horse has NOT been previously diagnosed with ulcers My horse has been previously diagnosed with ulcers If yes, when? How were the ulcers diagnosed? Gastroscopy Presumptive Were the ulcers treated? If so, with what? Duration of treatment & date of last treatment? Do you use an ulcer preventative? * Yes No If yes, what do you use and what dose? How do you use your ulcer preventative? Daily Traveling/Showing Only when showing signs of stress When was your horse dewormed last and what was used? * I agree to follow the IMPORTANT INSTRUCTIONS for my horse to have gastroscopy. I understand that the stomach MUST be empty. I understand it is critical to the success of the procedure to withhold feed (including hay, grass, grain and treats) and withhold all water from 4 pm the day BEFORE Dr. Newton completes the procedure. I agree to remove all hay and bedding from the stall, and to possibly muzzle my horse during the no food/no water time period so my horse does not ingest anything before the procedure. * First Name Last Name Date * MM DD YYYY * I agree to electronically sign this document by typing my name. Thank you!
