BORDER TERRIER BREED HEALTH GROUP

CECS Questionnaire

To be sent to Breed Health Coordinator Steve Dean:

Email –  stevedean@tyrianborder.com

 

Dog’s Details

 

Dog’s Home Name :

………………………………………………………………………………..

 

Dog’s Kennel Club Registered Name (if known):

……………………………………………………………………………….

.

Sex:    Male □            Female □

 

Age: ………………………

 

Birthdate: ………………………………….

 

Pedigree:      Yes □  No □

 

KC Registered Names of Parents If Known:

         Father:…………………………………………………………….

 

         Mother:………………………………………………………….

Are you happy for this information to be added to a Database held for research purposes by the Border Terrier Breed Health Group. □ Yes           □ No

 

 

 

 

The Episodes/Seizure

 

Dog’s age at which you first observed an episode: ……………………………….

 

Date of Last Known Episode:………………………………………………………

 

How often does the dog have these Episodes:

□          Weekly           □ Monthly      □ Every 2/3 Months

□          Every 6 Months        □ Once Per Year      □ Other :

 

Average Length of Episode:

□ <5 Mins      □ 5-10 Mins   □ 10-20 Mins

□          >20 Mins

 

Does the dog appear conscious during the episode:  □ Yes   □ No

Does the dog appear to be aware of surroundings during episode: □ Yes □ No

Can you get the dogs attention during the episode: □ Yes   □ No

Does the dog attempt to come to you during the episode: □ Yes □ No

Does the dog exhibit trouble walking during the episode: □ Yes □ No

Does the dog lie down during the episode: □ Yes     □ No

If yes does it tend to lie on one side or the other: □ Left   □ Right

Does the dogs show unusual head movement during the episode: □ Yes □ No

Does the dog exhibit excessive salivation during the episode: □ Yes   □ No

Does the dog exhibit air licking during the episode: □ Yes   □ No

Is the dog normal in between the episodes □ Yes   □ No

How long does it take for the dog to return to normal after an episode:

□Immediately □ 5 Mins        □ 15 Mins    □ 30 Mins    □ 1 Hour    □ > 1 Hour

 

 

 

Other Issues

Does the dog suffer from any of the following conditions (tick all that apply):

□ Hypersensitivity (Allergic) Skin Condition       □ Skin Cyst

□ Otitis Externa         □ Otitis Media            □ Lipoma

□ Chronic Itching     □ Conjunctivitis        □ Dermatitis

□ Arthritis       □ Epilepsy     □ Ear Mite Infection

 

Diet

What food is your dog usually fed:

□          Dry Food

o          Standard

o          Wheat Free

o          Hypoallergetic

        Brand:

 

□          Wet Food

o          Standard

o          Wheat Free

o          Hypoallergetic

        Brand:

 

□          Raw Diet

 

□          Special Diet :

 

Have you changed the dogs diet due to the disorder  □ Yes   □ No

If yes

         When did you change the diet: ………………………………..

         What change did you make:…………………………………………………

………………………………………………………………………………………………

Does the dog scavenge food outside or inside the home □ Yes □ No (For example hoovering up crumbs in the kitchen)

Does the dog have access to other sources of food, eg treats that you have not controlled □ Yes   □ No

 

Details of Veterinary Surgeon consulted:

 

Name:…………………………………………………………

Address:……………………………………………………….

…………………………………………………………

………………………………………………………..

Email address: ………………………………………….

 

 

Details of Owner:…………………………………………………………

Address:……………………………………………………….

…………………………………………………………

………………………………………………………..

Email address: ………………………………………….

 

Signature of Owner: …………………………………………………..

 

Date: ……………………………………m