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 *****

Email address *
Reporting Date *
MM
/
DD
/
YYYY
Veterinarian Name *
Your answer
Veterinary Clinic
Your answer
Veterinarian Phone *
Your answer
Veterinarian Email *
Your answer
Horse Owner Name *
Your answer
Owner Phone *
Your answer
Owner Address *
street address, city, state, zip
Your answer
Owner Email
Your answer
Address of Horse *
if different than owner
Your answer
County where horse resides *
Your answer
Horse Name *
Your answer
Horse Identification (microchip, tattoo, brand) *
enter N/A if no identification
Your answer
Age *
Your answer
Sex *
If mare, is she pregnant?
Breed *
Your answer
Color *
Your answer
Horse's Purpose
Number of horses on farm
Your answer
Number with neurological signs *
Your answer
Type of premises
Operation purpose
Clinical diagnosis or suspected conditions *
Your answer
Date of onset *
MM
/
DD
/
YYYY
Clinical signs *
check all that apply
Required
If febrile, indicate max temp *F
Your answer
History *
Your answer
Animal Status *
Has the horse traveled in-state in the previous 30 days?
If yes to in-state travel, please indicate date of travel and location(s)
Your answer
Has the horse traveled out-of-state in the previous 30 days?
If yes to out-of-state travel, please indicate date of travel and location(s)
Your answer
Current on the following vaccinations
Dates of last vaccinations in above question
Your answer
Treatment initiated?
If yes, please summarize treatment:
Your answer
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 *
Your answer
Date samples submitted *
MM
/
DD
/
YYYY
Laboratory submitted to *
Your answer
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