(EIC) Testing Form - Veterinary Diagnostic Laboratory - University of ...

Exercise Induced Collapse (EIC) - Submission Form - Dog # 5Animal InformationDog # 5 LabelCall NameBreedSexVeterinary Diagnostic LaboratoryUNIVERSITY OF MINNESOTA1333 Gortner Avenue. St. Paul, Minnesota 55108Contact Information - OwnerOwner NameCompany /Alternate ContactAddressCityCountrye-mailMaleDate of Birth (mm/dd/yyyy)ColorRegistered NameStateFemaleIntactZipYesNoPhone : (612) 625-8787Fax : (612) 624-8707Toll Free : 1-800-605-8787Attending Veterinarian (if any)VeterinarianClinicAddresse-mail : vdl@umn.eduWeb site :www.vdl.umn.eduCity State ZipPhone Fax PhoneFaxSubmission List (Page 1) : Dog # 5Please be sure toenclose theSubmission List(Page 1) of theEIC test formalong withpayment.For current test price,please see link:Fees and TestInformationCountryPayment MethodCheck#e-mailGift CertificateResult Reporting (Choose ONE):Money Ordere-mail: Owner Vet ClinicCredit Card(Authorization FormFax: Owner Vet Clinicattached)IND Re-submissionHistory & Physical FindingsVDL #DHas this dog experienced episodes of collapse (Specifically, loss ofcontrol of the rear limbs during highly exciting or stressful activity)?Yes No If yes, note all that apply:Rear limbs seem floppy, and don't seem to hold up the dog's weightDog drags its rear limbs while continuing to runDog seems to have trouble maintaining balance and will fall over to the sideDog's limbs seem stiffer than normal and held straight and stiffFront limbs Rear limbs BothOtherReg. #Tattoo / MicrochipTO UPDATE A DOG'S REPORT WITH REGISTRATIONINFORMATION AT A LATER DATE, A PERMANENT IDMUST BE VERIFIED AT THE TIME OF TESTING.Activities that cause collapse (check all that apply):Field Trial TrainingUpland Game HuntingSwimmingOtherHunt TestE-collar CorrectionFun BumpersSireDamType :Field Trial Hunt Test ConformationPetService OtherDoes your dog have a history of (check all that apply):Loss of Muscle MassSeizuresAbnormal Muscle BiopsyHypoglycemiaRespiratory DifficultiesAbnormal Heart RhythmAbnormal Thyroid FunctionNarcolepsyCranial Cruciate Ligament (CCL) Rupture Myasthenia GravisOwner's SignatureDateTo be completed by attending veterinarian or veterinary technician:I DID verify tattoo/microchip on this dog. I DID NOT verify tattoo/microchip on this dog.No tattoo/microchipSample TypeWhole BloodCheek SwabsSignatureDateSemenDew ClawsSYS.FORM.054, Rev. 17 08/05/2014Page 6 of 23