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Irish Wolfhound Seizure Study Dog Enrollment
updated 23 October 2021
Owner Information
Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone
Dog General Information
Call Name
*
Registered Name
Registration #
Date of Birth
(mm/dd/yyyy)
Gender
select one
Female
Male
Spay/Neuter?
select one
No
Yes
Sire's Registered Name
Dam's Registered Name
Number of Pups in Litter
Dog Housing:
House
Kennel
Is This Dog Still Living?
Yes
No
Date of Death or Age at Death
if you don't know the exact date/age, please estimate.
Was the Dog Euthanized?
select one
Yes
No
Cause of Death
Dog Diet Information
Main Diet
Select the diet type that best describes the majority of your dog's diet
select one
Raw commercially-formulated
Raw Pre-mix Commercial
Raw Home-prepared
Cooked Home-prepared
Kibble
Canned
Other
Diet Details
Please include brands for commercial diets
Medical History
Vaccination/Medication Information
DHLP/Parvo Given:
in combination
separately
DHLP/Parvo Interval Given
Heartworm Preventative Details
Flea and Tick Preventative Details
Seizure Medications (include dosages)
Other Medication Details (include dosages)
Seizure Information
Age or Date of Onset of Seizures
Frequency of Seizures
Seizure Occurrence
During sleep/rest
During the day
At night
Type of Seizure
Neurological Exams
Other Exams/Tests
Veterinarian Name and Contact Information
Other Information
Other Health Issues
Temperament Description
Other Comments
