1. Please enter your first name:

2. Please enter your last name:

3. Enter your city below:

4. Please enter your state of residency:

5. Please enter your zip code:

6. Please enter your area code:

7. Please enter your telephone number:

8. Please enter your email address:

9. Please enter your pet's name:

10. Pet's breed:

11. Pet's birthdate:

12. Dog's weight (in pounds):

13. Please enter your dog's gender below:          M, intact          F, intact          M, neutered          F, neutered

14. Age of seizure onset:

15. Cause of seizures (if known):

16. Is your pet on Phenobarbital treatment?          yes          no

17. Current Dose of Phenobarb?

18. Is your pet on Potassium Bromide?          yes          no

19. Current does of Potassium Bromide?

20. Please list any other anticonvulsants you are administering:

21. How often does your dog seizure?

22. When was your dog's last seizure?

23. On average, how many seizures per month does your dog have?

24. Are the seizures isolated events or do they occur in clusters?

25. Has your dog ever been hospitalized for cluster seizures?

26. Provide a brief desription of your dog's typical seizures:

27. Please indicate what type of heartworm medication your dog is receiving:          Heartguard (Ivermection)          Interceptor (Milbemycin)          Sentinel          None          Other

28. List any other medication your dog is currently taking:

29. List any other supplement your dog is currently taking:

30. Where did you acquire your dog?

31. Do you know of any relatives of your dog that also have seizures?

32. Referring RDVM name:

33. Referring RDVM Address:

34. Referring RDVM City:

35. Referring RDVM State:

36. Referring RDVM Zip Code:

37. Referring RDVM Telephone Number:

38. Date of survey submission:

39. Any general comments that you would like to add?