Cerebellar Hypoplasia Screening

Cerebellar Hypoplasia Screening
Your Name *

First Last
Your Preferred Method for Contact *

Phone Email
Your Email Address *
Your Phone Number *

Area Code Phone Number
Are you considering surrendering your animal to CH Lives Matter Rescue? *

Yes No
Which type of animal are you asking about? *

Cat Dog
Animal's Approximate Age *
How long have you had this animal? *
Where did you get this animal? *
Has the animal had any of the following procedures? Select all that apply. *

Neutering/spaying Vaccinations Tests None of these I don't know
If yes, please upload the corresponding documents.

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Has the animal received a diagnosis of cerebellar hypoplasia? *

Yes No
If yes, from whom? *
Is the animal exhibiting any of these characteristics? Select all that apply. *

Head bobbing High-stepping when walking General clumsiness and unsteadiness Standing with legs wide Tremors that get worse when moving or eating and might disappear entirely when asleep Swaying from side to side when standing or walking Chicken-pecking motion when eating None of these
Is this animal the only one in the litter affected with these characteristics? *

Yes No Unknown
What challenges is the animal currently experiencing? *
Is the animal currently taking any medication? *

Yes No
If yes, please list the medication(s) and corresponding dose(s) below. *
Please upload 3 videos of the animal: 1 of the animal walking for at least 10 seconds, 1 of the animal eating or drinking for at least 10 seconds, 1 of the animal doing something else natural for at least 10 seconds with no human interference. *

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