Dog Name_______________Male____Female_____Age_________Breed_____________
lst. symptom of DM_________________Date:_______________Age of dog_____________
Diagnosed by whom:Veteranarian:______Neurologist_________Date diagnosed:___________
Tests done to diagnose DM:___________________________________________________
_________________________________________________________________________
Any trauma 6 months before DM was diagnosed (fall, surgery, etc.)______________________
_________________________________________________________________________
Medication dog was on 6 months before diagnosed:__________________________________
__________________________________________________________________________
Any trauma 12 months before diagnosed (fall surgery)_________________________________
__________________________________________________________________________
Medication dog was on 12 months before diagnosed with DM:___________________________
__________________________________________________________________________
12 Month Progression of DM: ( please state first onset and duration of each)
Dragging leg:(note left or right)____________________________________________________
Scrape toes:(left, right)__________________________________________________________
Knuckling:____________________________________________________________________
Cross legs(tripping themselves)____________________________________________________
Can't get up by themselves:_______________________________________________________
Stops walking_____________Walks only by holding tail___________Walks only in cart________
Lost control of urine:_________________________Lost control of bowel___________________
Dog Euthanized:_______________Date:______________
Diet before diagnosed with DM_____________________________________________________
Diet after DM diagnosed:__________________________________________________________
Diet Now______________________________________________________________________
Vitamins or supplements before diagnosed:_____________________________________________
Vitamins or supplements after diagnosed:_______________________________________________
Vitamins or supplements on now:____________________________________________________
Have you used Dr. Clemmons recommended regimen:(diet, supplements, exercise): - please state below:
How long was dog on any or all of these(Dr.Clemons)______________Did dog improve, stay the same
or no noticeable change, get worse? state one which applies:_________________________________
What was the health of your dog before DM was diagnosed:_________________________________
As a puppy did you notice any unusual traits about your dog:_________________________________
Was dog exposed to chemicals of any sort (lawn chemicals etc.)______________________________
Any suggestions you can recommend that will help a dog with DM:___________________________
How often do you excise dog(walking) how many times a day_________
Has dog gone for swimming therapy______Did it help_______Accupuncture_____did it help___
Please answer all questions accurately, if you think of anything else to add that my be helpful please do so.
Please mail survey results to Eleanor at: ellym@systec.com