Equine Grass Sickness Surveillance

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Confidential New Case Report Questionnaire

Please use this form to report all NEW cases of equine grass sickness

PLEASE READ THESE NOTES BEFORE COMPLETING THE QUESTIONNAIRE:
1. This form is for one horse only. Please fill in a separate form for each horse.
2. Please answer all relevant questions and sections of this questionnaire.
3. Please write in BLOCK CAPITALS in the spaces provided.
4. Please fill in all three sections of this questionnaire.
5. For more information or clarification on any aspect of this study please contact Georgette Kluiters: Telephone 01638 555664 Ext: 1203 E-mail: georgette.kluiters@aht.org.uk

Section 1: Recent Equine Grass Sickness Case

This section contains questions about the most recent case of equine grass sickness (EGS) you are reporting.

1. What is the affected horse's name?

2. Where was the affected horse grazing when it developed clinical signs of EGS?

Address:

Town: Region/County:

Post Code:

3. What was the age of the horse when it was affected with EGS? Years Months

4. What was the sex of the affected horse? (Please tick one box only)
Mare/Filly Stallion/Colt Gelding

5. What is the breed of the affected horse?

6. When were clinical signs of EGS first observed? dd/mm/yyyy

7. Did the affected horse survive? (please tick one box only) Yes No: put down/euthanased by vet No: died naturally/found dead

8. Which one of the following best describes the clinical signs? (please tick one box only)

Colic: died/put down/euthanased within 48 hours (ACUTE GRASS SICKNESS)

Colic: died/put down/euthanased within 2-7 days (SUBACUTE GRASS SICKNESS)

Weight loss: survived longer than 7 days (CHRONIC GRASS SICKNESS)

Other (Please describe)

9. Which of the following best describes how the diagnosis was made? (Please tick all boxes that apply)

Name of Horse	Diagnostic Techniques
	Clinical Signs		Surgery		Post-Mortem Examination		Other: please describe
	By a veterinary surgeon	By owner/ keeper/ other non- veterinary personnel	With gut biopsy (histop-athology)	Without gut biopsy (histopa-thology)	With ganglia exami-nation	Without ganglia exam-ination
Example HAMISH
This Case

Section 2: The affected Premises

This section contains questions regarding the premises when the above case of EGS occurd.

10. Prior to becoming ill, how long had the horse been kept on:

a)the whole premises? b) the affected paddock?

11. What was the area of grazing available for horses on:

a) the whole premises? b) the affected paddock?

12. What was the total number of horses grazing, including the EGS case, on: a)
the whole premises horses b) the affected paddock? horses

13. Have there been any previous cases of EGS on: (please tick one box per option)

a) the whole premises Yes No Don't know
b) the affected paddock? Yes No Don't Know

14. Since what date are you aware of the history of the premises? (DD/MM/YYYY)

Section 3: Your Contact Details

This section contains questions about you and will remain confidential. We are proposing to follow up this study with a short questionnaire. Please indicate your preferred methods of communication, which are optional, by ticking the appropriate 'Contact Preference' boxes.

15. Title: Miss / Mr / Mrs / Dr / Other:

First Name: Surname:

16. Is your contact address the same as the address given for the horse in section 1?

Yes > If 'Yes' please go to question 17.

No > If 'No' please complete the following.

Address:

Town: Region/County:

Postcode:

17. Telephone Number:

18. Fax Number:

19. E-mail address:

20. What is your preferred method of contact? Mail Phone Fax E-mail

Please enter the date of completion of this questionnaire:

dd/mm/yyyy

Thank you for filling in this questionnaire. Please look below for contact details at the AHT.

This space is for you to make any additional comments that you may have on the questionnaire, this study or specific issues you feel are important. Please use this space to give us any more information that you think may be useful about your experience of EGS. Your input is welcomed:

This is a confidential study and we will not pass on any information to any other party without your permission. However, if you would like your details to be submitted to the Equine Grass Sickness Fund – the only charity dedicated to supporting and advancing research into grass sickness and further improving the treatment of chronic cases - then please tick here The Equine Grass Sickness Fund will then also be aware of your case and may contact you with more information about the disease.

Thank you for filling in this questionnaire.

EGS Diagnosis

EGS Prognosis

CGS Management