Owner Name
Patient Name
Pedigree
Name/Registration Number
Regular
Veterinarian
Phone
Address
Microchip Yes
No
Is your dog having clinical signs? Yes
No
If yes, check all that apply Shoulder Scratching
Neck Pain
Hind Limb Weakness
Fore Limb Weakness
How long has your dog been exhibiting these signs? (Frequency: hourly, daily, weekly, etc.)
Have these signs progressed over time?
Has your dog had a previous MRI or CT scan?
Yes
No
If yes, please state when and where
Has your dog had any previous surgery?
Yes
No
If yes, please state when, where, and what surgery was performed
Has your dog had any previous injuries?
Yes
No
If yes, please indicate what type of injury and where. Please include any scars and tattoos.
Has your dog been diagnosed with a heart murmur?
Yes
No
If yes, please state age at diagnosis. Please include dates of any cardiac ultrasound.
Has your dog ever had a seizure?
Yes
No
If yes, please state date of last seizure and frequency of seizures.
Has your dog been diagnosed with any other clinical diseases?
Yes
No
If yes, please state the disease and when it was diagnosed
Please list all medications your dog is currently taking
Have any of your dog’s siblings been diagnosed with a particular condition?
Yes
No
If yes, please state condition and when it was diagnosed.
