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.
Last Name		First Name
Phone number		Email
Dog’s name (call or nickname)		Dog’s registered name
Dog’s registration number		Breed
Dog's birthdate (mm/dd/yy)
Dog's Sex   Male Female 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.
To your knowledge have any of the following relatives of this dog had seizures? Siblings (full or half), parents, grandparents, or offspring Yes No Don't know If you answered yes to the last question, please describe the relationship of the other dogs who have had seizures to this dog. If you can provide information about the identity of those dogs (AKC number, owner's name etc.) please include that information also.

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.

Current veterinarian		Phone number
Previous veterinarian		Phone number
Veterinary neurologist		Phone number

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.

Please indicate whether each of the following tests were run when your dog was diagnosed with epilepsy and whether the results were reported as normal or abnormal.

Blood count (CBC)		Not performed	Normal	Abnormal	Don't know results
Serum chemistries		Not performed	Normal	Abnormal	Don't know results
Liver function (Bile acids or ammonia)		Not performed	Normal	Abnormal	Don't know results
Thryroid function		Not performed	Normal	Abnormal	Don't know results
Brain scan (CT or MRI)		Not performed	Normal	Abnormal	Don't know results
Spinal fluid analysis (spinal tap)		Not performed	Normal	Abnormal	Don't know results

 

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

Approximately what percentage of the time is your pet in direct supervision such that a seizure would likely to be identified? In other words, how much of the day are you or other members of your family with your dog?  ? <25 % 25-50% 50-75% >75%

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

Have you noticed any unusual behaviors by your dog immediately prior to their seizures?
Yes No

If yes, please describe what your dog does BEFORE the seizure.

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

Please describe a TYPICAL seizure. This section is very important to the success of the research. Describe carefully what your pet actually does during the seizure. Some important things to note are whether your pet appears conscious or responsive to you, whether they remain standing, sitting, or fall to their side, whether they drool or lose control of their bowels or bladder, what types of movements or postures you observe, and the order these things tend to occur in. Do not just enter a seizure type such as "grand mal" since there are many variations on these classifications.

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  

What does your dog do until he/she is behaving normally again?

 

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 intermitantly (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.

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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