Canine Epilepsy Research Consortium Seizure Survey
Thank you for helping with this important research. With your help, we hope to better understand epilepsy in dogs and improve our ability to prevent and treat this devastating disease. Please fill out the following questions. There will be a space at the end to enter additional comments.
Information about yourself and your dog
Has your dog been neutered (spayed or castrated)? Yes No
Dog’s current weight lbs.
Has this dog's sample been sent in for research? Yes No Not Yet, intend to do so
Are any relatives of this dog also affected with seizures? Yes No
If Yes, which relatives?
sibling half-sibling sire dam grandparent offspring aunt/uncle niece/nephew other
Information about your veterinarian and your dog's general health.
Has a veterinarian diagnosed your dog with epilepsy? Yes No
If yes, please list your current veterinarian and/or the veterinarian who diagnosed your dog with epilepsy. If you consulted with a veterinary neurologist, please list them also.
I give the researchers directly involved in the study permission to contact my veterinarian(s) for additional information about my dog's epilepsy. 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 permit my veterinarian to release the above information to the researchers.
If you know the results of any of the tests indicated as abnormal above, enter the value below. If other tests were done which are relevant to the diagnosis of epilepsy or if you have any comments about the tests, enter that information below.
Does your dog currently have any other serious health problems besides seizures? Yes No
Did your dog have any serious health problems when younger? Yes No
Were there any difficulties related to your dog's birth (prolonged delivery, death of littermates, illness of the mother, etc.)? Yes No I don't know
If you answered yes to any of the last three questions, please explain below.
Tell us about your dog's seizures.
What was your dog's age at the time of the first seizure? ? Less than 2 months old 2-6 months old 7-12 months old 1-3 years old 4-5 years old Over 5 years old
How long has it now been since the seizures first started? ? Less than 1 month 1-2 months 2-3 months 3-6 months 6-12 months 12-24 months 24-36 months Over 36 months
Please estimate how many seizures you dog has had since they first began (total number of seizures). ? 1 2 3-5 6-10 10-20 20-40 Over 40
How many times has your dog had more than 2 seizures in a 24 hour period (cluster seizures)? ? Never Once 2-4 times Over 5 times
On the average, approximately how frequently does your dog have a seizure or cluster of seizures? If you dog has a cluster of several seizures in a 24 hour period, but the clusters only happen every 4 weeks, answer "Every 3-5 weeks". ? More than once daily Every 1-2 days Every 2-7 days Every 1-3 weeks Every 3-5 weeks Every 5-8 weeks Every 2-3 months Every 3-6 months Every 6-12 months less than once a year
During which of the following activities does your dog typically have a seizure or begin a cluster? ? Anytime Upon awakening in the morning During strenuous activity, exercise or excitement During non-strenuous activity like walking Soon after eating After a prolonged period of not eating When resting quietly but not sleeping Soon after falling asleep After being asleep for a while Other (describe in comments section)
What time of day does your dog tend to have seizures or begin a cluster? ? Anytime 8am-4pm 4pm-12am 12am-8am
How long does the seizure typically last? Don't confuse the disorientation after the seizure with the seizure itself. ? Less than 2 minutes 2-5 minutes 5-15 minutes 15-30 minutes Greater than 30 minutes
If your dog has seizures that differ significantly from the typical seizure described above, please include a brief description of these episodes. Also if the seizures have changed in type or pattern over time, please explain how they have changed.
Does your dog behave abnormally for a period of time immediately after the seizure? Yes No If yes, please answer the next two questions.
How long does it typically take until your dog is behaving normally again? ? Less than 5 minutes 5-30 minutes 30-60 minutes 1-2 hours 3-6 hours 6-24 hours 1-2 days 2-7 days Over a week Never normal
How are you treating the epilepsy?
Is your dog taking any medication, supplements or other treatments to control the seizures? Yes No (if no skip next section)Routine Anticonvulsant Medication If your dog receives daily anticonvulsant medication, check each drug being given and complete the following information. If blood levels of anticonvulsant medication have been taken, and you have the results, please enter that information also. If you only give medication intermittently (for example during a cluster of seizures), do not enter those medications here. Drug Check here Amount* Strength of tablet or liquid Times per day Blood level Date level measured Phenobarbital ? 15mg(1/4grain) 30mg(1/2grain) 60mg(1grain) 100mg(1.5grain) 15mg/5ml liquid ? Once Twice Three Four Other Potassium bromide ? 100mg/ml 250mg/ml 1500mg capsule other(enter below) ? Once Twice Three Four Other Primidone ? 250mg 50mg 25mg/ml liquid ? Once Twice Three Four Other Neurontin (gabapentin) ? 200mg 300mg 400mg ? Once Twice Three Four Other Felbamate ? 400mg 600mg 600mg/5ml liquid ? Once Twice Three Four Other Clonazepam (Klonopin) ? 0.5 mg 1 mg 2 mg ? Once Twice Three Four Other Other anticonvulsant (please list) ? Once Twice Three Four Other * Number of tablets or volume of liquid in ccs or mls If your dog is on daily medication(s) to control the seizures, how effective has the medication been in controlling the seizures? ? Great benefit (75-100% decrease in seizures with medication) Good benefit (50-75 % decrease in seizures with medication) Some benefit (25-50% decrease in seizures with medication) Little benefit (<25% decrease in seizures with medication) Seizures have gotten worse in spite of medication If you give any additional medication only when your dog has a seizure, please list the drug and how it is administered. If you are giving any herbal treatments, nutritional supplements, or other therapies for the epilepsy, please list them below. Comments If you have any additional information which you think might be useful, or have any comments about these forms or our research, include them below. When you have completed the above information accurately, click on the "submit" button below to send us the information. In submitting this information, you certify that it is accurate to the best of your knowledge. You 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. You consent to the use of this information in this manner. You will see a copy of the information after it is submitted and will have the option of printing off a copy for your records. Clicking on the "reset" button will clear all the fields without submitting any information -------------
If your dog receives daily anticonvulsant medication, check each drug being given and complete the following information. If blood levels of anticonvulsant medication have been taken, and you have the results, please enter that information also. If you only give medication intermittently (for example during a cluster of seizures), do not enter those medications here.
If your dog is on daily medication(s) to control the seizures, how effective has the medication been in controlling the seizures? ? Great benefit (75-100% decrease in seizures with medication) Good benefit (50-75 % decrease in seizures with medication) Some benefit (25-50% decrease in seizures with medication) Little benefit (<25% decrease in seizures with medication) Seizures have gotten worse in spite of medication
If you give any additional medication only when your dog has a seizure, please list the drug and how it is administered.
If you are giving any herbal treatments, nutritional supplements, or other therapies for the epilepsy, please list them below.
If you have any additional information which you think might be useful, or have any comments about these forms or our research, include them below.
When you have completed the above information accurately, click on the "submit" button below to send us the information. In submitting this information, you certify that it is accurate to the best of your knowledge. You 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. You consent to the use of this information in this manner.
You will see a copy of the information after it is submitted and will have the option of printing off a copy for your records. Clicking on the "reset" button will clear all the fields without submitting any information
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