Welsh Springer Spaniel Club of America
General Health Survey - Form

This Dog's Overall General Health: Excellent Good Fair Poor Bad
At what age did your dog start having significant health problems (if any)?
Conformation title? Y N   Working titles? Y N
(Non-USA) Breeding certification? Y N   Therapy titles? Y N
Other titles
Is this dog living? Y N   Age at death (YY/MM)
Cause of death  
Was autopsy performed to determine cause of death? Y N
Euthanized? Y N   Reason for doing so

Spayed/Neutered? Y N   Why done?   Age done

Enter name of medicine(s) and any unusual reactions:
Flea Preventive     
Flea Treatment      
Heartworm Preventive
Heatworm Treatment  
Adverse Reactions   

Vaccinations. Check any of the following which the dog normally receives:
Rabies   Bordetella   Distemper   Lyme   Parvo  
Lepto   Hepatitis   Giardia   Titres only  
Other - specify
Adverse Reactions To
Symptoms

Diet. What ones do you feed the dog?
Dry   Canned   Homemade   BARF (bones and raw food)
Brand of Food  
Do you feed the dog supplements? Y N
Supplement List

Has your dog ever been given an anesthetic? Y N
For what procedure(s)?
Adverse Reactions     
Type of anesthetic/sedation used (if known)

Has this dog been x-rayed for Hip Dysplasia? Y N     Age(s) done
Hip Surgery? Y N   How many?
OFA Hip result     PennHIP DI: L  R
Other result    
Has this dog been x-rayed for Elbow Dysplasia? Y N   Age(s) done
OFA Elbow result
Has this dog had a CERF (eye) exam? Y N     Age(s) done
Indicate any abnormalties noted on the exam sheet:
Has this dog had a thyroid profile done?
T4 only: Y N     Age(s) done
Thyroid profile results
TGAA? Y N     Age(s) done     Results
Full Panel? Y N     Results

For the following conditions, please check any that apply. Feel free to write in notes or comments.  Where applicable, please indicate how the diagnosis was made, by lab test, by vet, or by yourself (lab, vet, self).  Please use the boxes below each section for these comments.

MISC:
01. Blue eyes  
02. Hernia / Where  
03. Cleft lip or palate  
Notes or comments:


GASTROINTESTINAL:
04. Inflammatory Bowel Disease (IBD)  
05. Intussuception  
06. Bloat  
07. Vomit or regurgitate more than 4-5 per year  
08. Regurgitating/vomiting food  
      Or bile only? Y N    
09. Bite undershot at 1 year  
10. Bite overshot at 1 year  
11. Megaesophagus  
12. Eats feces  
13. Pica (eating non-food items)  
   14. Other:  
Notes or comments:


SKELETAL:
15. OCD. / Location:  
16. Panosteitis / Age:  
17. Cruciate ligament tears  
18. Patellar luxation:  
      Medial R L   Lateral R L    
19. Arthritis. / Location:  
      Age at onset:  
20. Luxating tarsus (hock)  
21. Intervertebral disk disease  
   22. Other:  
   23. Were any surgeries required? Y N    
      Number? Describe:  
       
Notes or comments:


NERVOUS SYSTEM:
24. Meningitis (check one or more):  
      Viral   Bacterial   Aseptic  
      Age at diagnosis:  
25. Hypomyelination (tremblers)  
26. Epilepsy  
27. Seizures / Controlled by meds? Y N    
      Age at first seizure:  
28. Fly snapping behavior  
      Was a cause determined? Y N    
      Description:  
   29. Other:  
Notes or comments:


EYES:
30. Entropion / Number of surgeries:  
31. Ectropion  
32. Distiachiasis (Ectopic cilia)  
      Tearing Y N    
33. Cataracts / Age at diagnosis:  
      Type:  
      Surgery Y N   Blindness Y N    
34. Glaucoma / Age at diagnosis:  
35. Optic nerve hypoplasia: eye R L    
      Age at Diagnosis  
36. Coloboma eye R L    
      Age at Diagnosis  
   37. Other:  
Notes or comments:


EAR:
38. Ear hematomas  
39. Chronic ear infections  
      Type:  
   40. Other:  
Notes or comments:


SKIN:
41. Chronic hot spots  
      Cause (if known)  
42. Seborrhea  
43. Demodectic mange over 6 months  
44. Persistent staph infection (pyoderma)  
45. Allergies  
      Type:  
46. Depigmentation of nose, lips, eye rims.  
47. Autoimmune skin disease  
      Type:  
   48. Other:  
Notes or comments:


CANCER:
49. Bone, Location:  
50. Breast  
51. Muscle, Location:  
52. Lymphatic  
53. Leukemia  
54. Head (mouth, etc.), Location:  
55. Fibrosarcoma  
56. Hemangiosarcoma  
57. Mast cell tumors, Location:  
   58. Other:  
      Age at diagnosis for any of above:  
      Treatment:  
Notes or comments:


BLOOD PROBLEMS:
59. Anemia, Type:  
60. Hemophilia  
61. von Willebrand's Disease  
62. Autoimmune Hemolytic Anemia  
63. Idiopathic Thrombocytopenia  
   64. Other:  
Notes or comments:


HORMONE DEFICIENCIES:
65. Diabetes mellitus  
66. Cushing's Disease  
67. Addison's Disease  
68. Pituitary  
69. Hyperthyroid (high)  
70. Hypothyroid (low) see page 1  
Notes or comments:


KIDNEY PROBLEMS:
71. Cystitis (Bladder Infection)  
      How many? Age of first  
72. Stones  
73. Incontinence  
74. Ectopic ureter  
75. Renal failure / Age of diagnosis  
   76. Other:  
Notes or comments:


LIVER PROBLEMS:
77. Portosystemic Shunt Surgery? Y N    
78. Chronic Active Hepatitis (NOT infectious)  
   79. Other:  
Notes or comments:


HEART PROBLEMS:
80. Mitral Valve Defect  
81. Tricuspid Valve Defect  
82. Stenosis / Type:  
83. Murmurs / Where:  
84. Patent Ductus Arteriosus  
   85. Other:  
Notes or comments:


REPRODUCTIVE PROBLEMS - FEMALES:
86. Months between heats:  
87. Irregular heats  
88. Refusal to accept male  
89. Failure to conceive: how many times?  
90. Fading puppies  
91. Vaginal Infection  
92. Pyometra  
93. Mastitis  
94. Difficulty whelping  
      Describe:  
95. Reabsorb litters? How many?  
      How did you know?  
   96. Other:  
   97. Number in litters:  
       
   98. Number alive after 24 hours:  
       
   99. Number alive at 6 weeks:  
       
   A0. Planned C-section? Y N    
   A1. If not planned, how long in labor prior to surgery?  
       
   A2. How many whelped naturally prior to C-section?  
       
   A3. Of those delivered by C-section, number that survived  
       
Notes or comments:


REPRODUCTIVE PROBLEMS - MALES:
A4. Lack Of Interest In Female  
A5. Impotence (Inability To Breed Willing Female)  
A6. Sterility (No Sperm)  
A7. Abnormal Sperm  
A8. Undescended Testicles  
   A9. Other Abnormality of Testicles:  
B0. Genital Infection  
B1. Prostatitis / Age:  
   B2. Other:  
   B3. How many litters sired: Natural  
      AI Cold shipped  
      Frozen  
Notes or comments:


IMMUNE FAILURE
   B4. Has This Dog Ever Been Diagnosed With A Condition In Which Immune Failure  
      Was Suspected?: Y N    
      What was the condition:  
      How was the diagnosis made:  
Notes or comments:


TEMPERAMENT:
      How would you describe your dog's temperament? (Check all that apply):  
B5. Very Shy  
B6. Timid  
B7. Reserved  
B8. Confident  
B9. Protective  
C0. Very Friendly  
C1. Aggressive  
C2. Dog aggressive  
C3. Bitten a person  
C4. Rage Syndrome  
C5. Afraid of men  
C6. Afraid of other:  
   C7. Other:  
Notes or comments:


Please include any additional comments about this dog:

Does your dog have any ongoing or chronic medical problem not covered on this survey?:

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