Dog s name: Owner s name:.. Address: Postcode: Telephone No:. . Dog s Breed:
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1 If you have not yet sent a cheek swab DNA sample from your dog for our research, and would like to receive a cheek swab collection kit, please tick this box: Epilepsy Questionnaire Dog s name: Owner s name:.. Address:. Postcode: Telephone No:. . Dog s Breed: Sex: Male Female Neutered: Date of birth: / / Date questionnaire completed: / / Is your dog still alive: If no, please tell us his/her cause of death: Page 1 of 7
2 How old was your dog when he/she had the first seizure? Specify the date of the first seizure if known: If you cannot remember the precise age or date when your dog had the first seizure, would you be able to tell us whether your dog was: Less than 6 months old between 6 months and 6 years old More than 6 years old Has your dog had 2 or more seizures in his/her entire life? t sure Please describe in your own words what your dog does just before, during and soon after a seizure: Page 2 of 7
3 Are all seizures similar/ identical in appearance? t sure If no, please specify what differs Does your dog do any of the following during a seizure (please select all that apply)? become recumbent (lie down) have rhythmic body/leg shaking/running movements have twitches of his head muscles make chewing movements become unconscious/unaware of where he is and who you are salivate (drool) more than normal urinate (pee) with no awareness of doing it defecate (poo) with no awareness of doing it In the minutes/ hours following a seizure does your dog show any of the following (please select all that apply): disorientation, aggressive behaviour, acting fearful; restlessness, pacing, lethargy, deep sleep, hunger, thirst, wobbly when walking, blindness (bumping into things); other (please specify) Is your dog completely normal during the days between seizures? t sure If no, please specify what is abnormal Does a seizure ever occur while your dog is resting? t sure Page 3 of 7
4 Does a seizure ever occur while your dog is sleeping? t sure Does a seizure ever occur while your dog is exercising? t sure How long does the seizure generally last? Do you time the seizure with a watch? Yes No Has your dog ever had more than one seizure in 24 hours? Yes Not sure No Which tests have been performed by your vet to identify the cause of the seizures (please tick appropriate boxes)? test has ever been performed I am not sure if and which tests have been performed Physical examination Neurologic examination Blood tests Urine test Computed tomography (CT) of the brain Magnetic resonance imaging (MRI) of the brain Cerebrospinal fluid analysis Other, please specify Were any of these test results not normal? t sure Page 4 of 7
5 If yes, please specify which test results were not normal Luisa De Risio - Epilepsy questionnaire 2016 Can you please provide the dates in which seizures have occurred since the first seizure or at least in the past 12 months (feel free to attach to this questionnaire a copy of your dog s seizure diary) Is your dog being administered any of the following medications? (please provide a copy of your dog s medication diary if available) Phenobarbitone (Epiphen or Phenoleptil) Potassium bromide (Libromide or Epilease) Imepitoin (Pexion) Levetiracetam (Keppra) Gabapentin (Neurontin) Zonisamide (Zonegran) Pregabalin (Lyrica) Other (please specify) Do you think the medication/s has/have helped to decrease seizure number, frequency and severity? t sure If possible, could you please provide: 1. Video footage of one or more of the seizures ( chris.jenkins@aht.org.uk) 2. Copies of your dog s veterinary medical record 3. Copies of results of any diagnostic investigations performed since the seizures started Page 5 of 7
6 Would you consent to us contacting your veterinary surgeon if we need clarifications or additional information? Name of veterinary surgeon: Name of Practice: Practice Address: Telephone No: .. Please use this page to tell us anything else about your dog s seizures that you think we should know (continued on next page): Page 6 of 7
7 Thank you very much for completing this questionnaire Page 7 of 7
Would you consent to us contacting your veterinary surgeon if we need clarifications or additional information?
If you have not yet sent a cheek swab DNA sample from your dog for our research, and would like to receive a cheek swab collection kit, please tick this box: Epilepsy Questionnaire Date questionnaire completed
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