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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Microchip*YesNoIs your dog having clinical signs?*YesNoCheck 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?*YesNoPlease state when and where Has your dog had any previous surgery?*YesNoPlease state when, where, and what surgery was performed Has your dog had any previous injuries?*YesNoPlease indicate what type of injury and where. Please include any scars and tattoos. Has your dog been diagnosed with a heart murmur?*YesNoPlease state age at diagnosis. Please include dates of any cardiac ultrasound. Has your dog ever had a seizure?*YesNoPlease state date of last seizure and frequency of seizures. Has your dog been diagnosed with any other clinical diseases?*YesNoPlease 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?*YesNoPlease state condition and when it was diagnosed.