Call Name: Registered Name: Registration Number: Breed: Sex: Male Female Intact: Intact Neutered/Spayed Birth Date: Date of Death: Sire: Dam: What line(s) is your dog from? (Check all that apply): Field Trial Hunt Test Pet Conformation Other: What activities does your dog routinely participate in (check all that apply): Field Trial Running alongside an ATV or bicycle Hunt Test Waterfowl hunting Fun Retrieves(alone) Fun Retrieves(with other dogs) Agility Training Retrieves on land Guide/Service work Training Retrieves in water Flyball Upland Game Hunting Obedience Conformation Showing Search and Rescue Hiking/Jogging Other: Has your dog had one or more distinct episodes of abnormal behavior, mentation, posture, gait or collapse during his/her lifetime? Yes No If yes, please also complete the Episode portion of this questionnaire.
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1. How would you judge your dog's body condition right now? obese a little heavy, but in good shape in perfect condition thin 2. How would you judge your dog's temperament? excitable normal laid back 3. Rank your perception of your dog's aggressiveness, on a scale of 1(low or none) to 5 (high) towards the following: Other dogs People His/her territory Please describe any perceived aggression or add any additional comments in the space below: 4. Rank your perception of your dog's intensity and desire to retrieve or herd compared to other dogs you have trained,on a scale of 1 (low or none) to 5 (high): Additional herding comments: 5. Rank your perception of your dog's trainability and intelligence compared to other dogs you have trained on a scaleof 1(low) to 5 (high): Additional trainability comments: 6. Please check all of the following that apply to your dog. dog always indoors, in fenced yard, or on a leash dog always indoors, or on a leash dog is always outdoors in kennel run or a fenced in yard dog spends some time outdoors unobserved in an unfenced area dog is in training full time other (please describe): 7. Compared to other dogs, does your dog seem to be more or less tolerant of high temperatures and/or humdity? 8. Do you use an e-collar for training? how does your dog handle repeated correction?
Has your veterinarian diagnosed the cause of your dog's abnormal episodes? yes no If so, what was the diagnosis: List the results of any tests that were done during your veterinarian's investigation to find the cause of these episodes
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1. When was you dog's first episode noted? 2. What was the weather (temperature, humidity) like during the first observed episode? 3. What was the dog doing at the time of the episode(s)? 4. What did you see first? 5. If your dog's limbs seemed abnormal during the episode, were the front legs, hind legs, or both involved and in whatorder? Were all the limbs the same or were there differences between the front and hind legs during the episode? For example would you describe each limb as being weak, floppy, uncoordinated, or stiff (rigid) compared with normal? 6. Did your dog completely lose the ability to walk or move? If not, please describe how your dog moved/walked during the episode. 7. What did you do, and what happened next? Did your dog's posture or gait change during the episode? 8. Approximately how many episodes has your dog had? (Please answer with a number - even if estimated.) 9. Have all of your dog's observed episodes been very similar, or have there been differences? Please describe any differences and give the particulars of each of the episodes you can recall (including the activity/circumstances precipitating the event, the temperature and humidity at the time of the event and your description of the event). 10. How long do your dog's episodes typically last? 11. Have you noticed any unusual behaviors or any unusual symptoms in your dog immediately prior to any of his/her episodes? (If yes, please describe.) 12. Is there anything that you think seems to make your dog more or less likely to have an episode on a given day? (If yes, please comment.) 14. Would you estimate that the frequency and/or severity of your dog's episodes is changing over time? (increased,decreased, or stayed the same). Do you think it is easier or harder to induce an episode now compared with when you first noted the condition.? 15. Please describe what usually happens from the time your dog's episode stops until he/she is acting and walking 100% normal again, and estimate how long this typically takes. 16. Has your dog ever been evaluated by a veterinarian during or immediately after an episode? If yes, what testing was done? What were the findings? 17. Has your dog ever been hospitalized for an episode?(If yes, please comment.) 18. How many times has your dog had more than one episode in 24 hours? Never Once 2-4 times 5+ times 19. What time of day are a majority of your dog's episodes? 10PM-6AM 6AM-2PM 2PM-10PM variable 20. Is your dog always completely alert and aware during each episode? If not, please describe any abnormalities in your dog's mental condition during the episode (i.e. disoriented, unconscious, etc.) . 21. Is your dog always completely alert and aware after each episode? If not, please describe any abnormalities in your dog's mental condition or behavior (ie disoriented, unconscious, sleepy, agitated, anxious) that you may have noticed during recovery or in the time after an episode and estimate how long these abnormalities persisted. 22. Have you taken your dog's temperature during an episode of collapse? If so, what was it? 23. Have you ever noticed a change in the color of your dog's urine during or after an episode? If yes, please elaborate 24. Have you ever noticed a change in the color of your dog's gums during an episode? If yes, please elaborate. 25. Between episodes (other than the first 24h after an episode) does your dog seem normal to you? If no, please comment. 26. Is your dog on any medication(s) or other treatments to control the episodes? If yes, please give type, current dosage and frequency of dosing. (ie Phenobarbitol 60mg, 1 tablet twice a day). 27. If your dog is on medication(s), how would you describe the level of control of the episodes? Good control - no episodes even after participating in trigger activities Fair control - my dog has less episodes than before and it seems more difficult to induce an episode Poor control - the frequency and severity of episodes has not changed while on the medications No control - the frequency and severity of episodes has worsened while on the medications 28. Does your dog take any other medications or supplements? 29. Have you noticed any other factors that seem to relate to the ease/difficulty of episode control or that appear to trigger episodes in your dog? (If yes, please comment.) 30. Do you usually feed your dog a commercial dog food? If so, what brand and what time(s) of day do you feed your dog? 31. Indicate the age of your residence where your dog lived at the time the seizures began. less than 10 years old 10 to 30 years old 31 to 50 years old more than 50 years old unknown 32. How long had you lived in the residence when your dog's episodes began? less than one year 1 to 5 years 6 to 10 years more than 10 years 33. Has your dog ever had any major traumatic injuries such as being hit by a car, kicked by livestock, or major fight injuries? If yes, please describe the injury and indicate whether the injury occurred before or after the first observed episode in your dog. If it occurred after the episodes began, estimate whether the frequency and/or severity of the episodes has increased, decreased, or stayed the same since the injury. 34. Does your dog have any current medical problems other than these episodes? If yes please list the medical problem, indicate when it was first diagnosed, whether it is being treated and the treatment used. 35. Has your dog had major medical problems in the past other than these episodes? If yes, please list. 36. Has your dog ever had a typical epileptic seizure, where he/she falls over, loses consciousness and paddles his/her legs?If yes, please describe these seizure(s), how often they occur and when they were first observed in your dog. 37. Are you aware of any problems your dog or his/her dam had related to your dog's birth (such as prolonged delivery,maternal illness, high sibling death rate, etc.)?(If yes, please list.) 38. Did your dog have any major illnesses during his/her first 6 months of life? If yes, please elaborate and indicate dates. 39. Did your dog receive routine puppy vaccinations against distemper and parvovirus at approximately 6-8, 10-12, and 14-16 weeks of age? (If this was not the vaccine schedule used, please indicate all known vaccinations your dog received during the first 6 months of life). 40. In regards to vaccinations please indicate the following. Month and year of your dog's most recent distemper/parvovirus combination vaccination: Month and year of your dog's most recent rabies vaccination: 41. Is your dog receiving heartworm preventative? With what product? 42. Are you aware of episodes similar to those your dog is experiencing in any of your dog's relatives (full-sibs, half-sibs,sire, dam, grandparents, or aunts or uncles)? 43. Have you bred this dog?(If yes, how many litters and total offspring?) 44. Do any of your dog's offspring have similar episodes? 45. Are you aware of typical epileptic seizures (episodes of falling over, losing consciousness and paddling legs?) in any of your dog's relatives (full-sibs, half-sibs, sire, dam, grandparents, aunts or uncles or offspring)? If so, please describe the relationship. 46. Use this space for any other information about your dog that you would like to provide. 47. If your dog is deceased, please describe the cause or circumstances of death. I understand the above questions and have supplied complete and accurate information, to the best of my knowledge. I understand that this information will be available only to researchers directly involved in the study and that any publication(s) resulting from this research will refer to dogs by an anonymous code number only. I give the researchers directly involved in the study permission to contact my veterinarian(s) and to access information from my dog's medical record. Iconsent to the use of this information in this manner. Signed: Date: Thank you for your time. Please fax or email (email@example.com) 3 or 5 generation pedigree and a copy of your dog's medical record and relevant diagnostictests (if possible)
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