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	Home > VBS Faculty > James R. Mickelson > Canine And Equine Genetics Laboratory > Idiopathic Epilepsy > Online Survey

Online Survey

UNIVERSITY OF MINNESOTA Canine Epilepsy Research Project Seizure Survey for Affected Dogs

Dog Information

Call name:
Breed:
Birth Date:
Registered Name:
Date of Death:
Registration Number:
Sex:
Sire:
If neutered/spayed, at what age:
Dam:
Country of Origin:
Type/Usage:

Owner Information

Name:
Street Address:
City, State, Zip:
Country:
Phone:
Alternate Phone:
Fax:
e-mail:

Alternate Contact

Name:
Street Address:
City, State, Zip:
Country:
Phone:
Alternate Phone:
Fax:
e-mail:

If your dog is deceased, please describe the cause or circumstances:

1. Has your dog had more than 1 seizure in their lifetime?

Yes
No

2. Has your veterinarian diagnosed your dog with epilepsy?

Yes
No

List any known test results relating to the diagnosis of the cause of seizures (Fax or attach copies of tests if possible, or indicate below from whom they may be obtained)

Veterinarian Who Made Diagnosis:

Name:
Clinic:
Street Address:
City, State, Zip:
Country:
Phone:
Fax:
e-mail:

Current Veterinarian if Different:

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).

Number of males and females in litter:	males	females
Number of littermates known to be affected with seizures:	males	females
Number of littermates known to NOT be affected with seizures:	males	females
Number of littermates of unknown status:	males	females

28. (cont'd) Any other information you would like to provide regarding littermates or full siblings:

29. Do any of the following dogs related to your dog have seizures?

half-sibs	Yes	No	Unknown
parents	Yes	No	Unknown
grandparents	Yes	No	Unknown

(If yes to #28 or #29 please indicate the following if known:)
1. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

2. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

3. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

4. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

5. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

6. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

30. Has your dog ever been bred?(If yes, please specify numer of litters and number of offspring)
YesNo
If so, please indicate the number of litters and offsring
Litters
Offspring

31. To your knowledge do any offspring of your dog have seizures? (If yes, please indicate the following if known.):
YesNo
1. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

2. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

3. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

4. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

5. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

6. Relationship:
Call Name:
Reg. Name:
Reg. Num:
Owner Contact:

32. 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 add any additional comments in the space below

33. Do you have any other concerns about your dog's behavior?

35. Use this space for any other information about your dog that you would like to provide.

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 canine epilepsy 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). I consent to the use of this information in this manner.

Date
Signed

Notice of Privacy Practices

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