BEAGLE EPILEPSY RESEARCH PROJECT
INDIVIDUAL DOG QUESTIONAIRE

(For seizing and non-seizing dogs)                                                         Litter ID Code:_______________

Registered Name_________________________________________________ Call name________________
AKC#______________________________ Birth date_______________________________ Sex________   

Owner___________________________________ Alternate contact_________________________________
Address__________________________________     ____________________________________
            __________________________________      ____________________________________ 

Phone (day) (___)__________________________ (___)_______________________________
Phone (eve) (___)__________________________ (___)_______________________________
Fax               (___)__________________________ (___)_______________________________

E-mail _______________________________ ____________________________________

Blood or tissue sample submission date:________________________________
Does this dog exhibit any of the following conditions? (Attach particulars for any Yes answer)

Y – N Aggression
Y – N Allergies
Y – N Arthritis
Y – N Autoimmune disorders
Y – N Bleeding disorders
Y – N Cancer/ Tumors
Y – N Deafness / Hearing impairment
Y – N Ear infections
Y – N Eye diseases / problems (specify)________________		 Y – N Heart problems (specify)________________
Y – N Hernia (where?)______________________
Y – N Reproductive disorders
Y – N Seizures/Epilepsy
Y – N Skin/ Coat problems
Y – N Structural abnormalites(hip/elbow dysplasia)
Y – N Other (specify:_______________________
Y – N Other (specify:_______________________

Testing done on this dog:

OFA/PennHIP      Y – N age at test:_______        results________________#____________________
ACVO exam        Y – N age last tested:_______  results________________#____________________
Thyroid               Y – N age last tested:_______  result_________________
Allergy               Y – N age at last test:_______  result_________________
Heart                  Y – N age at last test_______   type of test_____________ result_______________

Other (please attach separate sheet)