CGAP Deceased Dog

Epilepsy Disease Questionnaire  

"Genetic Basis for Canine Diseases”

Canine Genetic Analysis Project (CGAP)

Department of Animal Science, University of California, Davis

Principal Investigators: Dr. A.M. Oberbauer and Dr. T.R. Famula


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Please note that underlined and bolded fields must be completed before your submission will be accepted.

Dog Information

Breed:   

Dog’s Registered Name:      Call Name:

AKC Registration #:  

Date of Birth (mm/dd/yy):       Date of Death (mm/dd/yy):  

Coat Color:          Sex:    

                                                                                            Paternal Grandsire Registered Name:

Sire's Registered Name:      

                                                                                            Paternal Granddam Registered Name:

     Sire's AKC Registration #:

 

                                                                                            Maternal Grandsire Registered Name:            

Dam's Registered Name:   

                                                                                            Maternal Granddam Registered Name:

      Dam's AKC Registration #:

           

If you could, please send a copy of your dog's pedigree with your name to the following address:

Oberbauer Lab

Canine Genetic Analysis Project (CGAP)

Department of Animal Science

University of California

One Shields Avenue

Davis, CA 95616-8521

 

Disease Information

Epilepsy:           Age at Diagnosis:  years   months 

Seizure Status:    

         Age at First Seizure:   years   months   

1.  How was epilepsy diagnosed?  Please provide as much detail as you can.

2.  Describe in as great of detail as possible a typical seizure (if the progression of seizure frequency and intensity had changed over time, please include details):

3.  If the dog was spayed or neutered, was epilepsy diagnosed prior to or after spay or neuter?  

4.  Include any details of known relatives with epilepsy (include registered names if known):

5.  General comments regarding animal’s health, including other health disorders and diagnoses:

 

6.  Has your dog ever had any type of head trauma?  Please explain in detail.

7.  List any medications the dog has taken over its lifetime.  Please denote if they were given pre or post epilepsy diagnosis.

Owner Information

First Name    Last Name  

Address  

 

City                State/Province (abbreviate) 

 

Zip/Postal Code           Country (if not USA)

 

Phone (area code + number)  

 

E-Mail

 

    Thank you for participating!