Please print out and complete this form to submit with serum samples from cases of dysautonomia. If you need a form faxed to you, contact us. Separate serum and ship overnight on ice to:

Dr. Dennis O'Brien
Department of Veterinary Medicine & Surgery
379 E. Campus Dr.
Columbia MO 65211

Owner's name
Dog's name
Dog's age
Duration of signs
Veterinarian's name	Dr.
Veterinarian's phone number or email

For each of the following potential signs of dysautonomia, please check whether they were present, absent or not recorded in this case.

Clinical signs	Present	Absent	Not recorded
Mydriasis
Absent PLR
Elevated third eyelid
Schirmer's tear test <5 mm/min
Dry mucous membranes
Cachexia
Distended bladder
Urinary incontinence
Dysuria
Regurgitation/megesophagus
Diminished anal tone
Diarrhea
Constipation

Use the back of sheet to list any other neurologic signs and any comments. Thanks for your help.
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