Chimney Rock Animal Hospital

Seizure Questionnaire Form

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

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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 *

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