Dog Information

 

Please choose a 6-digit number for identification purposes for this dog. Use a different number for each dog. Keep a personal record of each number.

 

Enter random 6-digit number

 

When filling out this survey, be careful NOT to hit "enter" after each line or you will send the survey and be redirected to a "submission" page. If this happens, click the "back" button to return to this survey, enter the same 6-digit number to identify the dog, and finish completing the survey. If you do not remember the 6-digit number you entered, it will appear at the bottom of the "submission" page.

 

Dog's current age (or list year of birth if deceased)

When each line is completed, "click" onto the next line. Do not hit "enter."

 Sex

 

Neutered or spayed?   (If so, at what age?)

 

Dog's adult height and average weight

 

Food your dog is fed (write all that apply, canned, dry, home prepared cooked, raw diet)

 

The main meat ingredient in my dog's food is (chicken, beef, lamb, fish, etc)

 

How is your dog housed? (mostly inside my home, mostly outdoors, indoor/outdoor, kennel, etc)

 

How much exercise does your dog get each day?

 

Activities your dog participates in (lure coursing, conformation, obedience, flyball, other)

 

If deceased, age at death

 

Cause of death or reason for euthanasia

 

 

Temperament

 

Describe your dog's temperament in new situations (outgoing, fearful, aloof, calm, etc)

 

Describe your dog's temperament at home 

 

With strangers my dog is (friendly, aloof, aggressive, etc)

 

With other dogs my dog is:

 

Does your dog exhibit any temperament problems?

 

 

 

Health Conditions

 

Allergies  list any known drugs, products, plants, foods, etc that your dog is allergic to

 

age at onset

 

have health tests been performed in this area?

 

Anesthesia  has your dog had a reaction to anesthesia?

 

Result?

 

Bite  Overshot, undershot, how many missing teeth, cleft palate, any other bite problems?

 

Cancer  Has your dog had cancer? If so, list where it developed and what type of cancer was diagnosed

 

age at onset

 

have health tests been performed in this area? If so, list results.

 

Cardiovascular  - Has your dog had heart arrhythmia, murmur, cardiomyopathy, failure, valve dysfunction, any other heart problems?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Dermatology  - Has your dog had allergies, chronic staph infection, "hot spots", pigment abnormalities, Demodex, chronic fungus infections, cysts, tumors, any other skin problems?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Endocrine  Has your dog had diabetes, Cushings Disease, Addisons Disease, Hypothyroidism, Hyperthyroidism, any other hormone condition?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Gastrointestinal  Has your dog had chronic diarrhea, chronic vomiting, bloat, megaesophagus, pancreatitis, malabsorption syndrome, chronically thin/poor eater, any other gastrointestinal problems?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Hematology  - Has your dog had Von Willebrand's Disease, Hemophilia (list type), low white blood cell count, other blood disorders?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Immune Disorders  - Has your dog had lupus, arthritis, auto-immune hemolytic anemia, any other immune problems?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Infectious Diseases  Has your dog had Lyme disease, Ehrlichiosis, West Nile Virus, Meningitis, or other infectious diseases?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Neurology  Has your dog had seizures (list type if diagnosed), disc disease (list which vertebrae were involved), paralysis, wobblers, tremors, deafness, hindquarter weakness in older dog, dementia, Axonal Dystrophy, fly-snap syndrome, any other neurological problems?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Orthopedic  Has your dog had arthritis, spondylosis, elbow dysplasia, hip dysplasia, Osteochondritis, Panosteitis, Patellar Luxation, HOD,  ligament/tendon problems, any other muscle/bone problems? 

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Ophthalmic  Has your dog had cataracts (list type), Corneal dystrophy, Progressive retinal atrophy, Persistent pupillary membranes, glaucoma, collie eye, other eye problems or unusual eye exam results?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Reproductive - female   At what age did your bitch first come into season?

 

How often are her seasons?

 

Has your bitch had vaginitis, pyometra, reabsorption of pups, abortion, c-section, uterine inertia, sterile, not enough milk for pups, mastitis, refused to nurse or care for pups, aggressive towards pups, any other reproductive problems?

 

age at onset

 

The following questions are for bitches that have been bred.

Age of bitch when first bred  

 

# of live pups born; # of still-born pups in first litter

 

# of live pups at 2 months

 

Age of bitch if/when bred second time  

 

# of live pups born; # of still-born pups in second litter

 

# of live pups at 2 months

 

Age of bitch if/when bred third time  

 

 # of live pups born; # of still-born pups in third litter

 

# of live pups at 2 months

 

Has your bitch been bred any other times?

 

How many pups were born with a hernia?

 

Have health tests been performed in the reproductive area? If so, list results.

 

Reproductive - male Has your dog had the following: monorchid, cryptorchid, will not breed, prostrate problems, abnormal semen, sterile, testicular atrophy (list cause), any other reproductive problems?

 

age at onset

 

Have health tests been performed in this area? If so, list results

 

Respiratory  - Has your dog had any allergic respiratory conditions (list condition), pneumonia, any other respiratory problems? 

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Urinary Tract - Has your dog had stones, infections, kidney failure, incontinence, any other urinary tract problems?

 

age at onset

 

Have health tests been performed in this area? If so, list results.

 

Vaccines - What vaccines has this dog been given? List ages when each vaccine was given.

 

Medications - What medications is your dog on?  (heartworm, seizure meds, allergy meds, etc)

 

Other conditions/comments - list any other health conditions your dog has with any test results. Or, list any other comments.