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UNIVERSITY OF MINNESOTA NEUROMUSCULAR LAB SHIVERS EPIDEMIOLOGICAL STUDY
VIDEO SUBMISSION FORM
Please make sure you also fill out the online survey. The information on this form should match the information entered online. Please send DVD videos of the highest possible quality. Videos MUST be in the following format: 1. Start with horse on a hard, flat surface 2. Horse must be shown from each side walking forward a distance of approximately 50 feet 3. Horse must then be shown backing up for a distance of approximately 50 feet 4. Each of the horse’s legs must be picked up and held for approximately 30 seconds 5. Make sure the horse’s entire body is visible at all times and include close up views of any muscle abnormalities, such as twitching or atrophy.
DATE _____________________________________
OWNER’S LAST NAME _______________________ FIRST NAME __________________________
OWNER’S PHONE NUMBER ___________________ E-MAIL _____________________________
NAME OF VETERINARIAN _________________________________________________________
VETERINARIAN PHONE NUMBER _____________________________________
REGISTERED NAME OF HORSE (IF ANY) ________________________________
NICKNAME OF HORSE ______________________________________________
BREED ________________________________ DATE OF BIRTH __________________________
ADDITIONAL COMMENTS (use back if necessary):
MAIL TO:
Dr. Molly McCue Veterinary Population Medicine |
