Gastroscopy History
Pacific Crest Equine Veterinary Services
Owner Name
First Name
Last Name
Horse Information
Name
Breed
Age
Sex
What discipline is the horse primarily used for?
Is the horse currently in active training/riding?
Yes
No
How many times per week is the horse ridden?
Training/Riding Workload
Light
Moderate
Heavy
Housing
Check all that apply
Stall
Paddock
Pasture alone
Pasture w/others
Dry lot alone
Dry lot w/others
Is hay provided during turnout?
Yes
No
Sometimes
How many hours does your horse spend in a stall per day?
How many hours does your horse spend in turnout per day?
Please provide any additional information about your horse's housing that you think may be relevant.
Diet
How many times per day is your horse given grain/concentrate?
None
Once
Twice
Three
Four or more
What type of grain/concentrate does your horse eat?
Please list any supplements your horse receives.
How many times per day is your horse fed hay/roughage?
None
Once
Twice
Three
Four
Continuous access
Types of hay/forage that your horse eats (check all that apply)
Alfalfa
Grass hay
Mixed
Oat
Other
What type of grass hay does your horse eat?
Forms of hay/roughage that your horse eats
Flakes
Cubes
Pellets
Other
List any medications given in the last 4 weeks and frequency of administration
Recent Stressful Event History
What has your horse done in the last few weeks?
Competition-Single Day
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Competition-Multi Day
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Trailered less than 4 hours
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Trailered more than 4 hours
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Increase in workload/training
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
New trainer or new stabling
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Change in herd dynamics
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Change in feed
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Other (illness/layup/injury, etc)
Less than 2 weeks
2-4 weeks
4-8 weeks
Greater than 8 weeks
Never
Has your horse experienced any of these in the last two months?
Colic
Eye Disease
Respiratory Disease
Lameness
Other
Clinical Signs of Ulcers
Is your horse displaying any of these signs? Select all that apply
Decreased performance
Off feed
Unwilling to work
Bad attitude/crabby
Cincy/girthy
Picky eater
Not gaining weight
Weight loss
Poor coat quality
Colic
Colic
Skip this section if your horse has not had colic
Are the colic episodes....
Mild (no treatment required)
Moderate (responds to banamine alone)
Severe (requires more than just banamine)
How often does your horse exhibit colic signs?
Date of last colic
Date
Ulcer History
Has your horse previously been diagnosed with ulcers? If yes, when?
How were the ulcers diagnosed?
Gastroscopy
Presumptive Diagnosis
Sensitive to pressure points
Other
Were the ulcers treated?
Yes
No
If your horse has previously been treated for ulcers, what product was used for treatment?
Duration of last treatment?
Date of last treatment?
Do you use ulcer prevention?
Yes
No
If you use ulcer prevention, what product is used?
If you use ulcer prevention, how often is it used?
Continuously
During stressful situations
Please elaborate on any ulcer prevention used, if applicable.
When was the horse last dewormed and what dewormer was used?
Submit
Should be Empty: