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Epilepsy Advice Service
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Please fill out the form
Name of Veterinary Surgeon
*
Name of Veterinary Practice
Address Vet.Practice
Postcode Vet.Practice
Country Vet.Practice
Telephone Vet.Practice
*
Fax Vet.Practice
*
Email Vet.Practice
*
Animal's name
*
Owner’s surname
*
Animal Age / Date of Birth
*
Breed
*
Sex:
*
M
MN
F
FN
Date / Age (in years) at first seizure
*
Weight (in kilograms)
*
extra file upload-1
Please make sure your upload is not more than 1mb each.
extra file upload-2
Please make sure your upload is not more than 1mb each.
extra file upload-3
Please make sure your upload is not more than 1mb each.
SEIZURE TYPE
Generalised
Focal
Myoclonic
please cross appropriate box
Other seizure type
Brief description
SEIZURE NUMBER AND FREQUENCY
Number of seizures in previous 3 events and date occurred ( dd/ mm/yy ) and/ or frequency (e.g. every 4 weeks)
Event 1 number of seizures
Date event 1
Event 2 number of seizures
Date event 2
Event 3 number of seizures
Date event 3
FREQUENCY =
OTHER COMMENTS
Recovery
Minutes
Hours
Days
very distressing for owner / dog
Drug side effects
Pelvic limb ataxia- mild
Pelvic limb ataxia- severe
Lethargy - mild
Lethargy - severe
Previous diagnostic tests
Yes
NO
please attach copies of reports / clinical history
file upload/Previous diagnostic tests
Please make sure your upload is not more than 1mb each.
Brain MRI normal ?
Yes
No
not performed
Anti-epileptic drug history medical history can be attached but please ensure it is clear what the 1) drug dose is (e.g. mg of tablet and number given per day) 2) what drug dose serum concentration relates to.
Anti-epileptic drugs/ hold ctr button on your keyboard to select more than one medicine
Phenobarbital currently prescribed
Phenobarbital never prescribed
Phenobarbital previously prescribed
Bromide currently prescribed
Bromide never prescribed
Bromide previously prescribed
Levetiracetum currently prescribed
Levetiracetum never prescribed
Levetiracetum previously prescribed
Topiramate currently prescribed
Topiramate never prescribed
Topiramate previously prescribed
Zonisamide currently prescribed
Zonisamide never prescribed
Zonisamide previously prescribed
Propentofylline currently prescribed
Propentofylline never prescribed
Propentofylline previously prescribed
Gabapentin currently prescribed
Gabapentin never prescribed
Gabapentin previously prescribed
Pregabalin currently prescribed
Pregabalin never prescribed
Pregabalin previously prescribed
Slow release phenytoin currently prescribed
Slow release phenytoin never prescribed
Slow release phenytoin previously prescribed
Valproic acid currently prescribed
Valproic acid never prescribed
Valproic acid previously prescribed
Carbamazepine currently prescribed
Carbamazepine never prescribed
Carbamazepine previously prescribed
Diazepam currently prescribed
Diazepam not never prescribed
Diazepam previously prescribed
Rectal Diazepam currently prescribed
Rectal Diazepam never prescribed
Rectal Diazepam previously prescribed
Clonazepam currently prescribed
Clonazepam never prescribed
Clonazepam previously prescribed
check the medicines from this list and specify below and on the right.
NAME OF MEDICINE 1
CURRENT DOSAGE / FREQUENCY
LAST SERUM CONCENTRATION (INCLUDING UNITS)
DATE LAST SERUM CONCENRATION
DOSAGE WHEN LAST SERUM CONC. OBTAINED
DATE STARTED THIS MEDICATION / LENGTH OF TIME ON THIS MEDICATION
PREVIOUS DOSE AND SERUM CONC. (inc DATE)
PREVIOUS DOSE & SERUM CONC. (inc DATE).
NAME OF MEDICINE 2
CURRENT DOSAGE / FREQUENCY
LAST SERUM CONCENTRATION (INCLUDING UNITS)
DATE LAST SERUM CONCENTRATION
DOSAGE WHEN LAST SERUM CONC. OBTAINED
DATE STARTED THIS MEDICATION / LENGTH OF TIME ON THIS MEDICATION
PREVIOUS DOSE AND SERUM CONC. (inc DATE)
PREVIOUS DOSE & SERUM CONC. (inc DATE)
NAME OF MEDICINE 3
CURRENT DOSAGE / FREQUENCY 3
LAST SERUM CONCENTRATION (INCLUDING UNITS) 3
DATE LAST SERUM CONCENRATION 3
DOSAGE WHEN LAST SERUM CONC. OBTAINED 3
DATE STARTED THIS MEDICATION / LENGTH OF TIME ON THIS MEDICATION 3
PREVIOUS DOSE AND SERUM CONC. (inc DATE) 3
PREVIOUS DOSE & SERUM CONC. (inc DATE) 3
NAME OF MEDICINE 4
CURRENT DOSAGE / FREQUENCY 4
LAST SERUM CONCENTRATION (INCLUDING UNITS) 4
DATE LAST SERUM CONCENRATION 4
DOSAGE WHEN LAST SERUM CONC. OBTAINED 4
DATE STARTED THIS MEDICATION / LENGTH OF TIME ON THIS MEDICATION 4
PREVIOUS DOSE AND SERUM CONC. (inc DATE) 4
PREVIOUS DOSE & SERUM CONC. (inc DATE) 4
Other Medicine information
Main reason for enquiry
Seizures not controlled
Unacceptable drug adverse affects
Other
The cost of this service is £75 (plus VAT within the European Union) – in the UK the veterinary surgeon is invoiced
Proposed manner of payment:
Proposed manner of payment:
*
cheque
bank transfer (if outside UK bank fees / commission must be paid by user of service)
Paypal (£5 surcharge)
If there are any queries then please contact
Neurology@goddardvetgroup.co.uk