Health Update for the Squamous Cell Carcinoma Study

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Health Update for the Squamous Cell Carcinoma Study

* Required Fields

Survey Password: *

1) What is your dog's name: *

1a) Breed: *

2) What is your dog's current age: *

3) What is your name:

First:* Last: *

4) Is your dog still living? *

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

4b) At what age did your dog pass away?

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

5a) What kind of cancer?

If other, please specify:

5b) At what age was the diagnosis made?

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) If your dog was diagnosed with toe cancer (squamous cell carcinoma or malignant melanoma of the digit), how many toes were affected?

Type in a number:

5f) Which toes on which foot were affected (eg: second toe, left front foot)?

5g) Did the toe cancer metastasize to other organs?

6) Detailed health information about your dog's family members is very useful to our research. Please indicate if any of your dog's relatives had SCC of the digit, SCC of another part of the body, malignant melanoma of the digit, other cancer, no cancer throughout their life or unknown.

6a) Sire *

6b) Dam *

6c) Paternal Grandsire: *

6d) Paternal Granddam: *

6e) Maternal Grandsire: *

6f) Maternal Granddam: *

6g) Any Siblings (littermates, full siblings, half siblings) with SCC of the digit, SCC of another body part, malignant melanoma of the digit?

Please list:

6h) Any Progeny with SCC of the digit, SCC of another body part, malignant melanoma of the digit?

Please list:

6i) Any other relative (Aunts, Uncles etc.) with SCC of the digit,SCC of another body part, malignant melanoma of the digit?

Please list:

7) 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?

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

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 These records are to remain in the Ostrander lab and will not be published, distributed or otherwise revealed outside of the laboratory and will be used only for canine health research purposes.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: () -

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