Questionnaire for Dogs Diagnosed with Scottie Cramp
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Owner’s information
Name:
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Mailing address:
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Phone number:
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Email address:
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NOTE: Text input blocks are shown as Bold Text in highlighted boxes. Double click the phrase
and begin typing. The text boxes will expand automatically to hold additional information.
Your Scottie’s information
1. What is your dog’s name?
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2. What is your dog’s pedigree name and AKC registration number (if available)?
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3. What is your dog’s date of birth?
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4. At what age did your dog first show signs of Scottie cramp?
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5. Please describe a typical episode including the period immediately before and after the
episode and the duration of the episode. Please also include a video of the episode.
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Questionnaire for Dogs Diagnosed with Scottie Cramp
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6. How often do the episodes occur?
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7. What are the triggers for episodes?
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8. Is there a way to limit the duration of an episode (e.g. place in a quiet place?)
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9. How long does it take to produce signs after being exposed to the normal trigger?
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10. Have the episodes changed in any way over your dog’s life?
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11. Has your dog been treated for Scottie Cramp?
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If yes, what treatment was used and was it effective?
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12. Does your dog have any difficulty negotiating stairs?
If yes, when did this problem start?
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YesNo
Questionnaire for Dogs Diagnosed with Scottie Cramp
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13. Does your dog have a head tremor when excited about something?
YesNo
If yes, when did you first notice it?
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14. Have you noticed any other neurological symptoms or abnormalities in gait?
YesNo
If yes please describe:
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15. Has your dog been seen by a veterinarian or a veterinary neurologist for this
YesNo
problem?
If yes, could you send us their report? If you don't have it, could you give us the name
and number of your vet or neurologist so that we can talk to them?
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16. Does your dog have any other health problems? Please list.
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17. Do any of the relatives (great parents, parents, sibling, cousin, and etc.) of
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your dog have Scottie cramp?
If yes, will the owners of these dogs agree to take part in our study and how can we
contact them?
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Questionnaire for Dogs Diagnosed with Scottie Cramp
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18. Have any relatives of your dog been diagnosed with Cerebellar Abiotrophy (CA) (also known
as Cerebellar Ataxia or Cerebellar Cortical Degeneration)?
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Additional Information:
Please describe how and when you will be submitting the video and blood sample.
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Please return this completed form by either
E Mail to (gurkase@ncsu.edu). Although this file was designed for Email submission, the
completed form can also be printed and then FAX’d or mailed.
FAX to 919 513 7301. Cover page should be marked for the attention of Dr. Natasha Olby,) or
Postal Mail to:
Dr. Ganokon Urkasemsin
NCSU College of Veterinary Medicine
4700 Hillsborough St.
Raleigh, NC 27606
Thank you for your help.
Natasha Olby Vet MB, PhD DACVIM (Neurology)