Newton Baker Insurance Services, Inc.

PO Box 247, LAKEVIEW, NC 28350
NATIONWIDE TOLL FREE 1-800-334-7733
FAX 1-800-874-3565
www.newtonbaker.com
We accept MasterCard, Visa, and American Express..

Horse Mortality Insurance

LOSS OF USE EXAMINATION

Name of Insured__________________________________ Name of Animal__________________________________

Age___________, Sex___________, Use_____________

Normal

Any Abnormal Findings

Body Conditions:

______

____________________

Eyes:

______

____________________

Upper Airway following exercise Clinical:

______

____________________

Endoscopically:

______

____________________

Palpation of Back:

______

____________________

Examination for Lameness at a walk and trot in a straight line and small circles in both directions on a hard surface:

______

____________________

Inspection of Stifles:

______

____________________

Fixation of the Patella: Left Not Possible____ Possible____

Fixation of the Patella: Right Not Possible____ Possible____

	Flexion Test		Palpation of Limbs Normal?		Response to Testers Normal?
	Neg.	Pos.	Yes	No	Yes	No
Left Forelimb	____	____	____	____	____	____
Right Forelimb	____	____	____	____	____	____
Left Hindlimb	____	____	____	____	____	____
Right Hindlimb	____	____	____	____	____	____
Comment on positive Flexions or Abnormal Findings:

Radiographs of the Navicular Bones, the Proximal Sesamoid Bones, the Fetlock Joints, and the Tarsal Joints were evaluated whereby the radiographic findings are descibed in four categories: 1(good), 2(satisfactory), 3(moderate), and 4(unacceptable).

Assessment of Radiographs:

Navicular Bones

LF______ RF______

Proximal Sesamoid Bones

LF______ RF______

Fetlock Joints

LF______ RF______

Tarsal Joints

LF______ RF______

Provide details of any degenerative changes, bone spurs, chips, or osteochondrosis seen on any radiographs taken:

Results of blood samples taken for investigation of banned substances or nsaids:_______________________________________

Are you aware of any history of unsoundness, injury, or disease on the following horse?__________________________________

Other findings or remarks:__________________________________________________________________________________________

Signature of Veterinarian______________________________________

Date of Exam_______________

Address____________________________________________________

Phone Number______________

Professionally We Serve ~ Personally We Care

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