Irish Wolfhound Health Update

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Irish Wolfhound Health Update

* Required Fields

Survey Password: *

1) What is your dog's registered name: *

1a) Breed: *

2) What is your dog's date of birth: * (mm/dd/yyyy)

3) What is your name:First:* Last: *

4) Is your dog still living? *

if yes, proceed to question 5.

4a) If deceased, what was the cause of death?

Other(please specify):

4b) Was your dog euthanized (put to sleep)?

4c) When (month and year) did your dog pass away?

(mm/yyyy)

5) Has your dog ever been diagnosed with cancer? *

If NO, proceed to question 6.

5a) If yes, what kind of cancer?

If other, please specify:

5b) When (month and year) was the diagnosis made?

(mm/yyyy)

5c)In what organ or on what part of the body was the tumor found?

5d) How was the cancer identified?

If other, please describe:

5e) Did the cancer metastasize (spread) to other organs?

6) Has your dog ever been diagnosed with Atrial Fibrillation (AF)?

7) Has your dog ever been diagnosed with Dilated Cardiomyopathy(DCM)?

If you answered NO to both question 6 & 7 proceed to question 10.

8) If you answered YES to question 6:

8a) When was the diagnosis of AF made?

(mm/yyyy)

8b) What kind of diagnostic tests were used? (check all that apply)

Auscultation (stethoscope)

Chest X-rays

Electrocardiogram (ECG/EKG)

Echocardiography

Other (please specify):

9) If you answered YES to question 7:

9a) When was the diagnosis of DCM made?

(mm/yyyy)

9b) What kind of diagnostic tests were used? (check all that apply)

Auscultation (stethoscope)

Chest X-rays

Electrocardiogram (ECG/EKG)

Echocardiography

Other (please specify):

10) If you answered NO to BOTH question 6 and 7:

10a) Was your dog ever tested for AF/DCM?

10b) If you answered yes to 10a, when did the most recent test take place?

(mm/yyyy)

10c) If you answered yes to 10a,What kind of diagnostic tests were used? (check all that apply)

Auscultation (stethoscope)

Chest X-rays

Electrocardiogram (ECG/EKG)

Echocardiography

Other (please specify):

11) Does/did your dog show any of the following symptoms (check all that apply):

Respiratory problems (coughing, excessive panting)

Weight loss

Distended belly

Weakness, lethargy

Loss of appetite

12) Has your dog ever been diagnosed with one of the following conditions (check all that apply):

Distemper

Parvo

Heartworm disease

Hypothyroidism

Autoimmune disease (if yes, please specify)

13) Detailed health information about your dog's family members is very useful to our research. Please indicate if any of your dog's relatives were ever diagnosed with Atrial Fibrillation (AF), Dilated Cardiomyopathy (DCM), Osteosarcoma, other cancer, no cancer throughout their life or unknown.

13a) Sire:

Atrial Fibrillation(AF)

Dilated Cardiomyopathy(DCM)

Osteosarcoma

other cancer

no cancer

unknown

Date of Diagnosis:(mm/yyyy)

13b) Dam:

Atrial Fibrillation(AF)

Dilated Cardiomyopathy(DCM)

Osteosarcoma

other cancer

no cancer

unknown

Date of Diagnosis:(mm/yyyy)

13c) Paternal Grandsire:

Atrial Fibrillation(AF)

Dilated Cardiomyopathy(DCM)

Osteosarcoma

other cancer

no cancer

unknown

Date of Diagnosis:(mm/yyyy)

13d) Paternal Granddam:

Atrial Fibrillation(AF)

Dilated Cardiomyopathy(DCM)

Osteosarcoma

other cancer

no cancer

unknown

Date of Diagnosis:(mm/yyyy)

13e) Maternal Grandsire:

Atrial Fibrillation(AF)

Dilated Cardiomyopathy(DCM)

Osteosarcoma

other cancer

no cancer

unknown

Date of Diagnosis:(mm/yyyy)

13f) Maternal Granddam:

Atrial Fibrillation(AF)

Dilated Cardiomyopathy(DCM)

Osteosarcoma

other cancer

no cancer

unknown

Date of Diagnosis:(mm/yyyy)

13g) Any Siblings (littermates, full siblings, half siblings) diagnosed with

Atrial Fibrillation (AF),Dilated Cardiomyopathy (DCM),

Osteosarcoma or other cancer?

Please list:

Specify the date of the diagnosis, if known: (mm/yyyy)

13h) Any Progeny diagnosed with Atrial Fibrillation (AF),

Dilated Cardiomyopathy (DCM),Osteosarcoma

or other cancer?

Please list:

Specify the date of the diagnosis, if known:(mm/yyyy)

13i) Any other relative (Aunts, Uncles etc.) diagnosed with

Atrial Fibrillation (AF),Dilated Cardiomyopathy (DCM),

Osteosarcoma or other cancer?

Please list:

Specify the date of the diagnosis, if known: (mm/yyyy)

14) Has your dog developed any other health problems for which he/she has received treatment by a veterinarian (i.e. arthritis, diabetes, thyroid problems, lameness, infection, etc.)? Has your dog been diagnosed with a second cancer in addition to the one listed above?

15) Is there anything we have not asked that you feel we should know about your dog's health?

I give my consent for the Ostrander lab to share portions of my dog's DNA sample and information about my dog with their relevant collaborators. No information or DNA will be shared with other members of your breed club or the AKC and its agents.

I give my consent for members of the Ostrander lab to contact my veterinarian in order to obtain health records for the dog named above. These records are to remain in the Ostrander lab and will not be published, distributed or otherwise revealed outside of the laboratory and will be used only for canine health research purposes.

a) Veterinarian's name:

b) Name of Vet clinic/hospital:

c) Veterinarian's phone number: () -

If possible, please fax or mail a copy of your dog's ultrasound, ECG/EKG printout, biopsy or pathology report to Dana Mosher, Ostrander Lab Samples Manager at Fx: 301-594-0023.

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