Equine Neurological Disease Case Report Form
Colorado Department of Agriculture - Animal Health Division
305 Interlocken Parkway, Broomfield, CO  80021-3484

Phone: (303)869-9130
Fax: (303)466-8515
Hours: Mon-Fri 8am - 5pm

***** After hours: Phone message will indicate staff veterinarian on call *****
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Email *
Reporting Date *
MM
/
DD
/
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Have you consulted with a CDA veterinarian about this case?   *
Name of CDA veterinarian contacted:
Veterinarian Name *
Veterinary Clinic
Veterinarian Phone *
Veterinarian Email *
Horse Owner Name *
Owner Phone *
Owner Address *
street address, city, state, zip
Owner Email
Address of Horse (complete physical) *
if different than owner
County where horse resides *
Horse Name *
Horse Identification (microchip, tattoo, brand) *
enter N/A if no identification
Age *
Sex *
Breed *
Color *
Horse's Purpose
Number of horses on farm
Number with neurological signs *
Type of premises
Operation purpose
Clinical diagnosis or suspected conditions *
Date of onset *
MM
/
DD
/
YYYY
Clinical signs *
check all that apply
Required
If febrile, indicate max temp *F
History *
Animal Status *
Has the horse traveled in-state in the previous 30 days?
Clear selection
If yes to in-state travel, please indicate date of travel and location(s)
Has the horse traveled out-of-state in the previous 30 days?
Clear selection
If yes to out-of-state travel, please indicate date of travel and location(s)
Vaccination Status *
Current on the following vaccinations *
Required
Dates of last vaccinations
Treatment initiated?
Clear selection
If yes, please summarize treatment:
What animals has the horse had contact with?
Where is the horse housed?
Specimen type submitted to lab *
check all that apply
Required
Number of animals sampled *
Date samples submitted *
MM
/
DD
/
YYYY
Tests requested
Laboratory submitted to *
Submit
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