Name: Clinic: Street Address: City, State, Zip: Country: Phone: Fax: e-mail:
Name: Clinic: Street Address: City, State, Zip: Country: Phone: Fax: e-mail: 3. Month and Year of first known seizure: 4. What was your dog's age at the time of the first known seizure? less than 6 months 6 months to 12 months 1 year to 5 years greater than 5 years 5. Approximately how many seizures has your dog had per year in the last two years? greater than 12/year 6-12/year 2-5/year 1-2/year less than 1/year 6. Has the number of seizures per year changed significantly since the onset of seizures? (If yes, please detail how the frequency has changed.) 7. Please estimate how many total seizures your dog has had since his/her seizures began. 2 3-5 6-10 11-20 20-40 greater than 40 (approx. number) 8. How many times has your dog had more than one seizure in 24 hours (seizure clusters)? Never Once 2-4 times 5 or more times 9. Has your dog ever been hospitalized for cluster seizures? 10. What time of day are a majority of your dog's seizures? 10 PM - 6 AM 6 AM - 2 PM 2 PM - 10 PM variable 11. Please describe what you observe when your dog has a typical seizure, including how long they typically last. 12. Have you noticed any unusual behaviors by your dog immediately prior to their seizures? (If yes, please describe.) 13. Please describe what usually happens from the time your dog's seizure stops until he/she is acting normal again, and how long this typically lasts. 14. Between seizures (other than up to one day after a seizure) does your dog appear normal? 15. Is your dog on any medication(s) or other treatments to control the seizures? If yes, please give type, current dosage and frequency of dosing. (ie Phenobarbitol 60mg, 1 tablet twice a day). 16. If your dog is on seizure medication(s), how would you describe the ease you have had in controlling the seizures? (Reasonable control is often considered a single seizure of less than 5 minutes duration, once every 6-8 weeks or less often.) easy moderately easy moderatley difficult difficult 17. Have you noticed any other factors that seem to relate to ease/difficulty of seizure control or that appear to trigger seizures? 18. 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 19. How long had you lived in the residence when your dog's seizures began? less than one year 1 to 5 years 6 to 10 years more than 10 years 20. 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 outdoors in an area unfenced and unobserved sometimes Other (please describe): 21. Has your dog had any major traumatic injuries such as being hit by a car or major fight injuries? ( If yes, please describe, and also indicate month and year of injury.) 22. Does your dog have any current medical problems other than seizures? (if yes, please list problems, indicate current treatments, and include when your dog was first diagnosed.) 23. Does your dog have any past medical problems other than seizures? (If yes, please list.) 24. 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 number, etc.) ? 25. Did your dog have any major illnesses during his/her first 6 months of life? 26. Did your dog receive the standard series of 3-4 injections of distemper/parvo as a puppy (at about 6-8,10-12, and 14-16 weeks of age)? 27. In regards to vaccinations please indicate the following: month and year of last distemper/parvo virus combination vaccination month and year of last rabies vaccination 28. Litter information (if known).
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