Welsh Springer Spaniel Club of America, Inc.
Proposed Epilepsy Registry Form


Welsh Springer Spaniel Club of America, Inc.

Epilepsy Registry Form

As fellow Welsh Springer Spaniel owners, we realize the distress you are feeling and we want to thank you for your help in gathering data that may let us eliminate this problem from our breed’s future. Members of the Welsh Springer Spaniel Club of America hold the protection and future well-being of the breed as one of their primary obligations. Please answer as many of the questions as you can, but don’t worry if you don’t know some answers. If necessary, the club will contact you for further information. If possible, please attach a three generation pedigree and a copy of the AKC Registration Certificate to this form. Thank you! Mail to: Karen Lyle, Secretary, WSSCA, W254 N4989 McKerrow Drive, Pewaukee, WI 53072

The Epilepsy Registry Form is designed to facilitate analysis of epilepsy and other factors that can lead to seizing dogs. This form contains a statement for you to sign that allows the club to disclose the information that you submit if your dog meets the registry qualifications. Initially, we will publish two lists. One will be for dogs that have had a seizure that seems likely due to hereditary causes. The other is for dogs that have produced these epileptic offspring.

If you own, or co-own, a dog who has seized, or who has produced offspring that seized, you may fill out and submit the form. If you co-own the dog, the co-owner(s) should sign the submission as well. You may also submit this form without the co-owner's signature, in which case the club will contact the co-owner. You may attach another page if you need more room for any response.

 

Information About You

Your Name:

Mailing Addresses:

City, State, ZIP:

Home Area Code & Telephone Number:

E-Mail Address:

Information About Your Dog

Registered Name of your dog:

Call name: AKC Registration Number:

Date of Birth:                Sex:

Date of First Seizure:

Date of Death (if applicable):

Co-owner’s name, if any:

Registered Name of Sire:

Registered Name of Dam:

Name of Breeder:

Breeder’s Address:

Breeder’s Home Area Code & Telephone Number:

Has your dog been bred? Yesr Nor

If so, has he or she produced seizing offspring? Yesr Nor

If you answered the above question ‘Yes’ and your dog has not had a seizure, you may skip the Medical History/Lab Workup sections and go directly to Any Additional Comments.

Your Dog’s Medical History

 

 

 

Your Dog’s Laboratory Workup

If possible, the blood work performed should include the following tests Although this is not mandatory, the information is very helpful. If the dog was put down to end pain or if funds were not available to do the blood tests, the form should still be submitted. Feel free to ask your veterinarian’s advice as well as the aid of our Board of Directors or the Head of the Health Committee. You may contact them through the club secretary at the address on the front of the form.

If copies of laboratory work related to seizing are available, please attach; otherwise, circle the appropriate response if known:

White blood cell count: High Normal Low       Attending Veterinarian:

Blood sugar level: High Normal Low       Vet Hospital:

Liver tests: High Normal Low       Address::

Kidney tests: High Normal Low

Blood lead: High Normal Low       Phone:

List any other tests that may have been performed:

Any additional comments

If you would like, include a short paragraph to explain the circumstances surrounding the seizure episode, or anything else you would like to put in the record.

 

 

 

Certification

I understand that by signing this form I affirm that the information that I have given is true and accurate to the best of my knowledge, and I agree that any or all of the information may be disclosed.

Owner X                                                                 Date:                  

Co-owner X                                                                 Date: