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EQUINE GRASS SICKNESS FUND

CASE FORM

If you have had a case of grass sickness, please complete this form.
If you prefer not to include your name and address please put the nearest town or the County.
The information submitted in this form will be treated in strictest confidence and will not be used for any purposes other than in connection with research into Equine Grass Sickness.

Name	_______________________________________
Address	_____________________________________________________________________________________
County	_______________________________	Post Code:	___________________
Tel No:	_______________________________	Email:	___________________________________________


Name of horse or pony:	________________________________________________________
Age __________	Sex __________	Breed ________________________________
Are you the owner ?	Yes	No
When did grass sickness occur ? ______________________________________________________
Nearest town to where the horse was kept when it became ill: __________________________________________

Was it:	Acute GS Subacute GS Chronic GS
Did the horse/pony
a) Die		If yes, was EGS confirmed by post mortem?	Yes	No
b) Survive		If yes, was it able to work after being ill?	Yes	No
Doing what ? ______________________________________________________________________
Any long-lasting problems ? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Your comments or observations: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Please return this form to:
Equine Grass Sickness Fund, Moredun Foundation, Pentlands Science Park, Penicuik, EH26 0PZ