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Health Update for the Malignant Histiocytosis 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:

6) 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.)?


7) Is your dog currently taking medication? *
If so, please list:


8) Is your dog on a veterinary prescribed diet, dietary supplement, and/or exercise program? *
If yes, please describe.


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 These records are to remain in the Ostrander lab and will not be published, distributed or otherwise revealed outside of the laboratory and will be used only for canine health research purposes.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