YES! Prescreen My Dog "*" indicates required fields THANK YOU FOR YOUR INTEREST IN THIS FREE CLINICAL STUDY FOR DOGS WITH THUNDERSTORM AVERSION. This brief questionnaire will help us determine if your dog is eligible to be screened for the study. More than one dog? If you have more than one dog that may qualify, please complete a separate questionnaire for each. Note however, only one dog per household may participate. "*" indicates required fieldsPlease select the location of the study site nearest you:*Select from this drop-down list:Acadiana West, Marrero, LA 70072Animal Center, Zachary, LA 70791Bradford Park, Springfield, MO 65804Harborside, Naples, FL 34104Loch Haven, Orlando, FL 32803Tomoka Pines, Ormond Beach, FL 32174Baker Veterinary Clinic, West Palm Beach, FL 33406Braden River, Bradenton, FL 34208Coastal Sunrise, Pensacola, FL 32504Pet Calls, Lake Worth, FL 33467St Francis, Navarre, FL 32566Brandt Veterinary Clinic, Nokomis, FL 34275None are close to meWe’re sorry, it appears there’s not a participating site in your area. If your dog continues to have problems, please reach out to your own veterinarian, or check back later, as new study sites may be added in the future. Thank you for your interest.Date: May 18, 2024GENERAL INFORMATION ABOUT YOUR DOG1. Does your dog weigh at least 8.8 pounds?* Yes No We’re sorry, but dogs must weigh at least 8.8 pounds to participate in this study. Thank you for your interest.2. What is your dog’s age? (Choose one)* Less than 6 months 6 months to 1 year Over 1 year We’re sorry, but dogs must be at least 6 months of age to participate. Thank you for your interest.3. Is your dog pregnant, or intended for breeding?* Yes No We’re sorry, dogs that are pregnant or intended for breeding are not eligible. Thank you for your interest.4. Is your dog participating in another clinical study?* Yes No We’re sorry, but dogs that are participating in another study are not eligible. Thank you for your interest.5. Does your dog have a history of aggression, such as being aggressive towards people or other dogs in your home?* Yes No We’re sorry, but dogs with aggression are not eligible to participate in this study. Thank you for your interest.6. Does your dog have epilepsy or has your dog taken epilepsy medication in the last 6 months?* Yes No We’re sorry, but dogs that have epilepsy or have taken epilepsy medication in the last 6 months are not eligible. Thank you for your interest.7. Has your dog received any of the following medications in the past 14 days? fluoxetine (brand name Prozac®), clomipramine, acepromazine, diazepam, amitriptyline* Yes No Please be aware that ongoing use of any of the above medications may disqualify your dog from study participation unless you are willing to consider discontinuing administration. If, however, you are consulting with your veterinarian about discontinuing use of the medication(s), please proceed with this questionnaire.8. Does your dog have any medical conditions?* Yes No Please describe:* 9. Does your dog suffer with chronic/constant pain?* Yes No 9a. Is your dog’s pain controlled through medication or other methods?* Yes No 9b. Please describe how your dog’s pain is being controlled (name of medication or other means):10. Please list all medications and supplements your dog receives, including flea and tick medication, heartworm medication, vitamins, special diet, etc.:*10a. Is one of the medications or supplements listed given to your dog for anxiety?* Yes No 10b. How often does your dog receive the anti-anxiety medication or supplement? (Choose one.)* Every day Only as needed (such prior to, or during events that cause anxiety) Please indicate the most recent date (day, month, year) you gave this medication or supplement to your dog:* Month Day Year YOUR DOG’S HISTORY OF FEAR OF THUNDERSTORMS1. When NOT receiving anti-anxiety medication(s), what signs of fear does your dog exhibit during thunderstorms? (Choose all that apply.)* Running around Drooling Hiding Destructiveness Cowering (such as tucks tail, flattens ears) Aggression (growling, snapping, biting) ‘Freezing’ to the spot Self-harm Restlessness/Pacing Panting Vigilance (on alert, scanning the surroundings) Bolting Owner-seeking behavior Barking, Whining, and/or Howling Trembling and/or shaking Vomiting and/or diarrhea or inappropriate urinating or defecating Other signs [Write in] Other (Please Describe)* 1a. Does your dog show fear in response to specific sounds during storms, such as thunder, wind, rain?* Yes No 1b. Does your dog ALWAYS show fear in response to loud noises? (Examples include fireworks, gun shots, or thunder)* Yes No 1c. Does your dog demonstrate fear even while you (or the owner), or another family member is present?* Yes No 2. Has any behavior modification been tried with your dog (such as playing thunderstorm sounds or other desensitization efforts) for the thunderstorm anxiety?* Yes No 2a. Please describe:*2b. How recently did your dog receive the behavior modification? (Please choose one)* March 2024 or after Before March 2024 ABOUT YOU & YOUR DOGIt appears your dog may be eligible for screening. If you wish your dog to be considered for this study, please fill in the following so that we may contact you. (We will NOT use your info for any purpose other than this study, nor will it be shared with anyone outside the study.)Dog's Name* Your Name* First Last Address* Street Address City State Zip Code Phone*Email* How did you learn about the study? (Check all that apply)* Facebook Instagram Friend My veterinarian Google Search Online search Other (write in) Other* Does your dog receive veterinary care?* Yes No Prefer not to answer Clinic Name:* Clinic Address (City, State)* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Clinic Phone*Do you have any upcoming vacation plans during the next 3 months?* Yes No Please note that due to the need for the dog to stay in its normal environment during the study, extended owner vacations may make dogs ineligible. This will be reviewed with owners at the screening visit. Please prove you are human by selecting the heart. NameThis field is for validation purposes and should be left unchanged.
