 SINGLE CHANNEL |
12 HOUR |
48 HOUR |
| DUAL CHANNEL |
24 HOUR |
_______ |
| |
OWNERS NAME: ____________________________________________________________________________
OWNERS ADDRESS: _________________________________________________________________________
CITY: ___________________________ STATE/PROVINCE: __________________ ZIPCODE: _____________
PHONE: _______________________________________ EMAIL: ____________________________________
DOGS NAME: ______________________________________________________________________________
REGISTRATION NO.: _____________________________________ BREED: ____________________________
GENDER: Female Spayed Female-Not Spayed Male Neutered Male-Not Neutered
BIRTHDATE: ____________________________ WEIGHT: _______________ specify pounds or kilograms
DATE OF RECORDING: _______________________________________________________________________
RECORDER S/N NO.: ________________________________________________________________________
|
| |
| TIME OF TEST: |
START _______________ AM |
STOP_______________ AM |
| |
_______________ PM |
_______________ PM |
| |
| PLEASE ANSWER THE FOLLOWING QUESTIONS TO HELP US INTERPRET YOUR STUDY |
Has this animal ever had any
episodes of collapse? |
YES |
NO |
| |
| Is this animal on any medications: |
YES |
NO |
| |
If medications are given, please list the name of the drug, amount given (milligrams) and frequency of dosing
(once a day, twice a day, etc). |
MEDICATIONS: _________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
|
