1. Sex of Dog with Epilepsy or seizures:

Male Female
Do not include dogs with other known causes of seizures, i.e.,head injury, etc)

Dalmatians only please.

 

Age at onset of seizures:
Current age of dog:

Please indicate which type your dog is experiencing:
Mild - Noticeable difference in dog of short duration. Momentary loss of consiousness, staring into space, loss of muscle tone and possibly upward rotation of the eyes "Petit Mal".

Partial - Partial Seizures: Movements are restricted to one area of the body, such as muscle jerking, movement of one limb, turning the head or bending the trunk to one side, or facial twitches.

Moderate - Loss of consciousness with generalized convulsions, paddling of limbs, frothing at the mouth, maybe urination and defacation. Usually last 1-3 mins but may last longer. "Grand Mal"

Severe - Loss of consciousness with generalized convulsions. Dog does not regain consiousness between attacks or medical help must be sought to stop seizure activity. "Status Epilepticus"

Cluster - Cluster Seizures:- Multiple seizures within a short period of time with only brief periods of consciousness in between. Maybe confused with Status Epilepticus. Both cases are considered life threatening.
 

How often does the dog have a seizure?
Is the dog on medication?
Please include the Drug, dosage and frequency of seizures. If the dog is on medication and no longer seizures, give the names of the drugs and doseage and then answer "0" to frequency. If you know the frequency of the seizure activity prior to medication please fill in both blanks.

Frequency of seizures without medication:


Frequency of seizures with medication:


Medication information:


Example:
Frequency of seizures without medication: 4 per month
Frequency of seizures with medication: 1 per month
Medication information : Dilantin 100mg, 3 times per day

Is the dog:
Intact. Neutered. Spayed.
5. Have you ever lost a dog due to seizure disorder?
Yes. No.
6. Are you aware of any incidence of seizure activity in any other family members?
Number of Family Members Affected: ... if none enter '0'.
7. Please provide any other information, questions or comments regarding seizure disorders:

Yes. No.

Please add your electonic signature to the form so that you can subit an updated survey in the future should things change with your dog.  All personal information received will be kept confidential by the research committee. Thank you for agreeing to complete this survey and for your continued interest in achieving excellence in Dalmatians.
 
 

Electronic Signature:
Dogs Name:
Your Name:
Your Email Address: