Seizure Form

Name *

First

Last

Email *

Phone *

When did you observe the first event?

If there have been multiple events, approximately how frequently do they occur?

If there have been multiple events, when was the most recent event?

Describe the abnormal activity observed:

How long do the event/s last?

Do you notice a behavior change before the event? How long does this last?

Do you notice any change after the event? How long does this last?

Has your pet been exposed to any known toxins?

Were there any previous testing/s performed to find the underlying cause for the event/s (bloodwork or other)?

Were there any previous and/or current treatment/s given for the event/s?

Does your pet currently receive medications to treat the events?

If so, please specify name of drug, # of milligrams per tab/cap, how many given each time, how often, and when started

Were there any recent change in the medication dose?

Are there any medications that your pet received previously to treat the event/s? When it was stopped and why?

Were there any side effects from the medications? If so, please describe:

Please list any other medical problems in your pet's history:

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