Canine Dysautonomia (CD) Research Survey

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This survey is meant to obtain information on dogs that have been diagnosed or highly suspected cases of Canine Dysautonomia (CD). This survey is administered by the Wyoming State Veterinary Laboratory (WSVL) and University of Wyoming. The time impact of this survey is 20 minutes.

How did you hear about this survey?

Your Name: (Not Required)

Email Address:

Physical Address:

Zip/Postal Code of affected animal: *

Relationship to animal: *

Practitioner

Owner

Other

Name of animal: *

Age of affected dog (months): *

Please provide age in full months. If exact age is unknown, please estimate. (Example: If dog's age is 3 yrs, 4 months, please answer 40.)

Sex of animal: *

Male

Female

Is animal sexually intact?

Yes

Clear selection

Breed(s): *

When did clinical signs start? *

MM/DD/YYYY

When was a CD diagnosis made? *

MM/DD/YYYY

Number of litter mates:

To the best of your knowledge, were any of the litter mates affected by CD?

Yes

Unknown

Clear selection

Birthplace of animal: *

How was animal acquired by current owner? *

Predominant environment: *

Unsupervised outdoor

Supervised outdoor

Mixed

Supervised indoor

Unsupervised indoor

Predominant use of animal: *

Working (ranching etc.)

Recreational (hunting etc.)

Family pet

Other:

Main use of property: *

Ranch

Farm

Recreation

If ranch, what animals were/are present on the property?

If farm, what animals were/are present on the property?

Other animals on property: *

Cattle

Birds (Chicken, ducks, etc.)

Horse

Cats

Sheep

Dogs

None

Other:

Required

Chemicals used on property: *

Herbicides

Fungicides

Pesticides

Insecticides

Unknown

Required

Please list specific chemicals used:

Please list all supplements and medications. *

List brands and dosing schedule

Please list all vaccines and other prescription treatments (e.g. deworming). *

Also list dates and brands used (lot numbers as well if available).

How was diagnosis made? *

Pharmacologic

Clinical Signs

Histology

Other:

Required

Please state which pharmacologic testing took place and the results:

Please list clinical signs that were noted and date of onset and severity:

Please list what histology was completed:

Is the animal still alive? *

Yes

If the animal is not alive, when did the animal die?

MM/DD/YYYY

How did the animal die?

Chemical Euthanasia

Natural Causes

Complications from CD

Other:

Clear selection

Veterinarians Name, Address, and Phone number *

Was a necropsy done? If so where, when, and who.

What is the dog's diet? *

Dry Commercial

Raw Commercial

Wet Commercial

Dry Special

Raw Special

Wet Special

Other:

What is the brand of the diet?

What is the dog's housing? *

Indoors house

Indoor kennel

Indoor garage

Outdoor doghouse

Outdoor kennel

Outdoor

Other:

Animal's water sources: *

Well water

County/City tap water

Pond water

River/Stream water

Rain water

Other:

Required

Any recent construction or digging on property? *

Yes

If yes, please describe (When, what):

Is the animal known to consume dirt or rocks? *

Yes

Unsure

Any wildlife exposure? *

Yes

If yes, please describe:

Any recent consumption of wildlife? *

Yes

If yes, please describe:

Any travel within or outside of your state? *

Yes

Unknown

If yes, please describe:

Any insect (spiders, ticks, etc.) bites on affected animal, other animals on property, or humans?

Yes

Clear selection

If yes, please describe:

Any other information you feel might be helpful:

May we contact you should we need further information?

Yes

Clear selection

Please supply preferred contact information:

Submit

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