Online Survey for Equine Metabolic Syndrome

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Thank you for your interest in participating in equine metabolic syndrome (EMS) research. We are currently not accepting additional horses into the study but if you would like to fill out the survey and submit your horse' s information for involvement in future EMS studies you are welcome to do so.

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Contact Information

Your Name:

Phone Number:

Your e-mail:

Horse's Call (Barn) Name:

Horse's Registered Name:

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Veterinarian Information

Veterinarian Name:

Clinic Name:

Clinic Address:

Clinic Phone:

Veterinarian/Clinic e-mail:

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Signalment

Horse's (approximate) year of birth? 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

What breed is the horse? American Cream Draft Andalusian Appaloosa Appendix QH (QHxTB) Arabian Bavarian Warmblood Belgian Canadian Warmblood Cleveland Bay Clydesdale Dutch Harness Dutch Warmblood Fox Trotter Friesian Gelderlander Haflinger Hanoverian Holsteiner Hussein Icelandic Horse Irish Draft Irish Sport Horse Lipizzaner Miniture Horse Mixed Breed: please specifiy in space below Morgan Mustang National Show Horse New Zealand Sport Horse Norwegian Fjord Oldenburg Paint Paso Fino Percheron Peruvian Paso Pinto Quarter Horse Rheinlander Rocky Mountain Horse Russian Orlov Trotter Saddlebred Shire Standardbred Suffolk Punch Swedish Warmblood Tennessee Walking Horse Thoroughbred Thoroughbred X Thoroughbred X Draft Thoroughbred X Warmblood Trakenher Warmblood Welsh Cob Welsh Pony Westfalian unknown
Other:

What is the horse's gender? Male, Intact Male, Castrated Female, Intact Female, Spayed

Would you describe your horse as an
"easy keeper" (tends to gain weight easily)? Yes No Not Sure

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Laminitis

Has your horse been previously diagnosed with laminitis? Yes No Not Sure

Please fill in the blank with any additional medical conditions
occurring at the time of laminitis if "yes" was selected for
the previous question?

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Phenotype

Is your horse overweight? Yes No Not Sure

Is your horse underweight? Yes No Not Sure

Does your horse have a thick, cresty neck? Yes No Not Sure

Does your horse have fat pads on its rump? Yes No Not Sure

Does your horse have haircoat that sheds later
in the year? Yes No Not Sure

Does your horse have thick or long curly haircoat? Yes No Not Sure

Does your horse urinate more than normal? Yes No Not Sure

Does your horse drink more than normal? Yes No Not Sure

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Previous Lab Work

Has your horse had any of the following lab work done?

Insulin Level: Yes, High Yes, Normal Yes, low Not performed

Glucose Level: Yes, High Yes, Normal Yes, low Not Performed

Dexamethasone Suppression Test: Yes - Normal Suppression Yes - Abnormal Suppression Not Performed

How many other horses are kept on the same
property as your horse? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16-20 21-25 26-30 31-35 36-40 41-45 45+

How many other horses kept on the same property
have experienced laminitis in the past? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+

How many other horses on the same property are overweight
or have been diagnosed with equine metabolic syndrome? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+

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May we contact you for more information? Yes No

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