Welsh Springer Spaniel Club of America, Inc.
Proposed 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. Or, if you prefer, submit this form and the club will contact the co-owner.

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:

Date of First Seizure:

Date of Death (if applicable):

Co-owner’s name, if any:

INFORMATION ABOUT YOUR DOG’S LINEAGE

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? Yes -- No

If so, has he or she produced seizing offspring? Yes -- No

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

Were all the vaccinations current during puppyhood and as an adult, especially distemper? Yes -- No

Any history of trauma, such as being hit by a car or falling that caused a loss of consciousness? Yes -- No

Any severe medical illnesses, such as uterine infection, temperature over 104, or liver/heart disease? Yes -- No

What was the time span between seizures? Did the time increase or decrease between seizures as time went on?


Did the seizures change over time? Yes -- No Briefly describe the seizure(s).





Was the seizure associated with any event that could have triggered the episode -- For example, a heat cycle or pregnancy? Yes -- No
If applicable, how long after the cycle or pregnancy did a seizure occur?


What, if any, medications were used? What was the response? Were any blood tests done to measure response?






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.

CBC(complete blood count)

SGPT

Total protein

BUN

Calcium

Glucose

Sodium

Potassium

Chloride

T4 (Thyroid)

If copies of laboratory work related to seizing are available, and attached, please skip the rest of this section. Otherwise, circle the appropriate response if you know what it was:

White blood cell count: High Nomal Low Unknown

Blood sugar level: High Nomal Low Unknown

Liver tests: High Nomal Low Unknown

Kidney tests: High Nomal Low Unknown

Blood lead: High Nomal Low Unknown

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 ........................