Sending Farm Name

Receiving Farm Name

Date Received

Number Received

For the following fields, please indicate the number of head showing the specified symptom. If none, enter '0'.

Coughing
Number of Head:

Sneezing
Number of Head:

Snotty Noses
Number of Head:

Scours
Number of Head:

Less Than 5 lbs
Number of Head:

Ruptures
Number of Head:

Uncastrated
Number of Head:

Lames/Stiff Pigs
Number of Head:

Swollen/Malformed Joints
Number of Head:

Observable Abscesses or Prolapses
Number of Head:

General observations regarding pig quality and conditions: