Seizure Questionnaire Form

Save time during your next appointment! Complete your required seizure questionnaire form from any device at any time before your visit.

get started

Online Form

Seizure Questionnaire Form

Client's Name *

First

Last

Phone number *

Patient's Name *

Species *

Breed *

Sex *

Age *

How many seizures has your pet had in the past 6 months? *

What activity was going on prior to seizure:

Exercise
Sleeping
Eating
Playing

Were other animals or people present (besides primary owner)?

Please check all symptoms seen: *

Muscle contractions
Clenching Jaw
Falling over/loss of balance
Blank or "SpacedOut" Stare
Drooling/Foaming
Paddling with feet
Vocalizing
Urination
Defecation
Other

How long do they typically last? *

< 30 sec
30 sec - 1 min
1-3 min
> 3 minutes
> 10 minutes

How long does it take to recover (post ictal period)? *

Have there been any recent changes to environment?

Moved
Houseguest(s)
New animal
New family member
Primary family member being home more/less
Stressor on family member

Have you noticed any changes in behavior/mentation, personality, gait or coordination?

Agression
Disorientation
Excessive vocalization
Wandering/blindness
Difficulty with coordination

Is there an inciting event? (Feed, play, exercise etc)

Do you give any medication or supplements? *

If yes, please describe

Any known past history of trauma, especially to the head? *

If yes, please describe

Has there been any head-shaking, scratching at ears, pain around ears, ear discharge or odor? *

If yes, please describe

Does your dog have any of the following breeds in his/her lineage that you are aware of:

Husky
Australian Shepherd
Border Collie
German Shepherd
Leonberger

How is your pet's health otherwise?

Any other conditions recently or currently being treated? *

If yes, please describe

Signature *

Date *

ready to visit?

Your Trustworthy Vet In Abilene, TX

We proudly serve the pets in Abeline, Wylie, Park Central Area, River Oaks/Brookhollow, Elmwood Area, Potosi, Red Bud Area, Tuscola, and surrounding communities. We look forward to seeing you and your pet soon. Easily keep up with your pet’s health by downloading our app!

Book Appointment

Download app