Please fill out a separate questionnaire for each dog that is being brought in for screening.Owner Name* Patient Name* Pedigree Name/Registration Number* Regular Veterinarian* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Microchip* Yes No Is your dog having clinical signs?* Yes No Check all that apply: Shoulder Scratching Neck Pain Hind Limb Weakness Fore Limb Weakness How long has your dog been exhibiting these signs?Have these signs progressed over time?Has your dog had a previous MRI or CT scan?* Yes No Please state when and whereHas your dog had any previous surgery?* Yes No Please state when, where, and what surgery was performedHas your dog had any previous injuries?* Yes No 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 Please state age at diagnosis. Please include dates of any cardiac ultrasound.Has your dog ever had a seizure?* Yes No Please state date of last seizure and frequency of seizures.Has your dog been diagnosed with any other clinical diseases?* Yes No 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 Please state condition and when it was diagnosed.
