Survey, Rider

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Post Ride Survey Form

Please complete this form ONLY if your horse experienced lameness or metabolic problems specifically related to this ride, whether at the ride or after leaving. Please be thorough, to the best of your knowledge, and include comments. You may remain anonymous OR include your name, but, PLEASE respond.

Your Contact Information
Last Name:		First Name:		Middle Initial:
Email Address:		Phone Number:		Member ID#:

Ride Identification
Name:		Date:		Region:
Distance:		Difficulty (1-10):		Did you finish?	YES NO
Time to Finish:		Number of Vet Checks:		Total Hold Time:
Your placing:		Total Riders:
Total Number of Vets:			Was that a sufficient number of vets?:		YES NO
Weather Conditions

Horse and Rider Information
Horse		Lifetime Mileage
Age		Sex		Years Competing
Rider		Lifetime Mileage
Age		Sex		Years Competing

Problem Experienced/Reason for Non-Completion
Lameness	YES NO
Please be specific, i.e. location, diagnosis

Metabolics (check all that apply)	YES NO
Tying Up	Colic	Failed to Recover		Other (please Specify)
		PULSE
		CRI

Miles Complete when pulled
Was treatment required for any of the above conditions?		YES NO	Comments:
In your opinion, was the Vet staff competent and prepared (equipment, supplies, etc) to handle the treatment?		YES NO
Did this horse require treatment within 72 hours of the ride for a condition not observed or treated at the ride?		YES NO	If yes, what diagnosis?
Did you continue treatment at home or at a referral clinic?		YES NO
	If yes, please specify details.
	Naso-Gastric tube?	YES NO	If yes, with what?
	IV fluids?	YES NO	If yes, how many liters?
	Medications?	YES NO	If yes, what medication?
	Other?	Comments
	Duration of treatment?
	Has the problem been resolved?	YES NO
	Had any of the problems associated with this ride been observed in this horse previously?	YES NO
	If yes, please provide details (dates, etc).

	Your opinion as to the recovery and future ability to compete on this horse.

Phone: 530.823.2260
Toll Free Number: 866-271-AERC
Fax: 530.823.7805
Email: aerc@foothill.net

Mailing address:
AERC
P.O. Box 6027
Auburn, CA 95604

Visit us at:
1373 Lincoln Way, Suite B
Auburn, CA 95603

Kathleen Henkel
AERC Executive Director
Email: kathleen@foothill.net

AERC Staff

Suzi Sousa - Finance - Email: aercaccounting@foothill.net
Judy Hall - Records Coordinator - Email: judyhall@foothill.net
Troy Smith - Publications - Email: endurancenews@foothill.net

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