Canine Exercise Induced Collapse (EIC) Testing Form
Veterinary Diagnostic Laboratory
UNIVERSITY OF MINNESOTA
1333 Gortner Avenue. St. Paul, Minnesota 55108
Phone : (612) 625-8787
Fax : (612) 624-8707
Toll Free : 1-800-605-8787
e-mail : vdl@umn.edu
Web site :
www.vdl.umn.edu
For office use
only.
Owner Name
Contact Information - Owner
Attending Veterinarian
Company
Address
Country
e-mail
Veterinarian
Clinic
Address
City
State
Zip
Country
e-mail
Phone
Fax
Fax
Phone
Zip
State
City
Clinic's Patient ID (if any)
Animal Information
Breed
If Yes, Registered Name
Call Name
Is this Dog Registered?
Yes
No
Reg. #
Date of Birth (mm/dd/yyyy)
Field Trial
Hunt Test
Conformation
Type :
History & Physical Findings
Female
Male
No
Yes
Pet
Sex
Intact
Tattoo / Microchip
Sire
Dam
Both
Rear limbs
Front limbs
The dog's limbs seem stiffer than normal and held straight and stiff.
Dog seems to have trouble maintaining balance and will fall over to the side.
Rear limbs seem floppy, and don't seem to be able to hold up my dog's weight.
If yes, note all that apply:
Yes
Has this dog experienced episodes of collapse (Specifically, loss of
control of the rear limbs during highly exciting or stressful activity)?
No
Color
e-mail
Fax
Phone
Result Reporting
No tattoo/microchip
Date
I DID NOT verify tattoo/microchip on this dog.
Signature
I DID verify tattoo/microchip on this dog.
To be completed by attending veterinarian:
Dew Claws
Blood
Semen
Sample Type
Cheek Swabs
Fun Bumpers
E-collar Correction
Hunt Test
Swimming
Upland Game Hunting
Field Trial Training
Activities that cause collapse (check all that apply):
Narcolepsy
Abnormal Heart Rhythm
Hypoglycemia
Abnormal Muscle Biopsy
Myasthenia Gravis
Abnormal Thyroid Function
Respiratory Difficulties
Seizures
Loss of Muscle Mass
Does your dog have a history of:
Other
Other
Other
Billing
Enclosed
Bill to Clinic
CK#
Pay by Credit Card,
please call
(612) 625-1246
Canine Exercise Induc