Canine Dysautonomia (CD) Research Survey
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.
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How did you hear about this survey?
Your Name: (Not Required)
Email Address:
Physical Address:
Zip/Postal Code of affected animal: *
Relationship to animal: *
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: *
Is animal sexually intact?
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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?
Clear selection
Birthplace of animal: *
How was animal acquired by current owner? *
Predominant environment: *
Predominant use of animal: *
Main use of property: *
If ranch, what animals were/are present on the property?
If farm, what animals were/are present on the property?
Other animals on property: *
Required
Chemicals used on property: *
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? *
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? *
If the animal is not alive, when did the animal die?
MM/DD/YYYY
How did the animal die?
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Veterinarians Name, Address, and Phone number *
Was a necropsy done?  If so where, when, and who.
What is the dog's diet? *
What is the brand of the diet?
What is the dog's housing? *
Animal's water sources: *
Required
Any recent construction or digging on property? *
If yes, please describe (When, what):
Is the animal known to consume dirt or rocks? *
Any wildlife exposure? *
If yes, please describe:
Any recent consumption of wildlife? *
If yes, please describe:
Any travel within or outside of your state? *
If yes, please describe:
Any insect (spiders, ticks, etc.) bites on affected animal, other animals on property, or humans?
Clear selection
If yes, please describe:
Any other information you feel might be helpful:
May we contact you should we need further information?
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Please supply preferred contact information:
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