Questionnaire
on Pet Behavior During Owner's Seizures
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| First
Name: |
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| Last
Name: |
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| Address: |
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| |
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| Phone
(day): |
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| Phone
(eve): |
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| Email: |
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Information
on Person with Seizures
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| 1)
Present Age: |
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| 2)
Sex: |
F
M |
| 3)
Types of seizures (please describe each type): |
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| 4)
Frequency of seizures (for each type described above): |
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| 5)
If this questionnaire is completed by a person other than the person
with seizures, what is your relationship to the person with seizures? |
Spouse
Parent
Sibling
Other(specify)
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Information
on Pet (please fill out 1 form for each animal)
|
| 1)
Pet: |
Dog
Cat
Other (specify)
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| 2)
Pet's age now: |
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| Pet's
age when obtained: |
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| Breed:
|
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| Sex:
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F
M
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| Neutered?
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Y
N |
Pet's
Behavior During Seizures
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| 1)
Do you believe the pet is aware of an oncoming seizure before you
are? |
Y
N |
| If
yes, how does the pet behave? |
|
| 2)
Does the pet respond during a seizure? |
Y
N |
| If
yes, what is the behavior? Describe what the pet does. |
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| 3)
Does the pet respond after a seizure? |
Y
N |
| If
yes, what is the behavior? Describe what the pet does. |
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| 4)
Does the pet alert others in the household to the seizures? |
Y
N |
| If
yes, describe the pet's behavior before, during and after seizure. |
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| 5)
Has this behavior of the pet ever been witnessed by anyone else? |
Y
N
If yes, by whom?
Family
Friends
Others (specify)
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| Additional
comments: |
|
 As
an alternative you may consider printing and mailing this form to:
The Epilepsy Institute, 257 Park Avenue South, New York, NY 10010 |
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