SWELLING & LUMP HISTORY FORM
Northeast Pennsylvania Equine Clinic
Client Question Form for Appointment and Patient Record
Date:___________________ Phone Number(s):______________________________________________
Client:__________________________________ Patient Name:_________________________________
Breed:_________________________________________Age:______________Sex:_________________
Verify Location:_______________________________________________________
When Noticed? ______________ Has it gotten worse since noticed? Yes ______ No ______
Size: ______________________________
Circle consistency: fluidy, soft, moderately firm, firm, hard like bone
Location on the horse: _____________________________________
Is the overlying skin and hair normal? Yes ______ No ______
If not normal, describe (any open sores, scabs, drainage, infection)__________________________
_______________________________________________________________________________
Painful? Yes ______ No ______
Warm or hot to the touch? Yes______ No _______
Behavior normal? Yes ______ No ______ Body temperature (normal 99-101.3): _______
Eating & Drinking well/normal? Yes ______ No ______
Please send us a digital picture by email as an attachment if at all possible to ejohnson@nep.net
If surgical treatment or removal is appropriate, can you trailer your horse in to the clinic? Yes____No____
Additional History/Comments: