Registered Name:Call Name:
Registration number:Birth Date (mm/dd/yyyy):
Date of Death (mm/dd/yyyy):
Sire:Dam:Sex:Male Female Intact Neutered/Spayed
Has this dog been diagnosed as being affected with polyneuropathyand/or laryngeal paralysis. If yes, indicate how and by whom (biopsy, EMG,nerve conduction study, laryngeal scoping, etc). If available, please attach a copyof the test results to the reply email you will recieve upon completion of this form.Yes: No:
Knuckling/Dragging toes:Yes: No:Age first noticed:Stumbling:Yes: No:Age first noticed:High-stepping gait:Yes: No:Age first noticed:Hitched gait:Yes: No:Age first noticed:Exaggerated stomping of the rear limbs:Yes: No:Age first noticed:Muscle atrophyYes: No:Age first noticed:If yes, which limbs were involved?Front RightFront LeftRear RightRear LeftFeel free to elaborate on your answers to the above questions:
Spinal Disc Disease
Torn Cruciate Ligament
Would you like us to share your dog's DNA with the Broad Institute Cancer Study?They need both affected and normal older dogs.
Please elaborate on any checked items (age diagnosed, method of diagnosis, interventions taken, level of control achieved, etc.)Does your dog have any other medical conditions or additional signs?If deceased, please state the cause or circumstances of death.
I am willing to provide additional blood or cheek swab samples if needed for research.Yes: No:I am willing to consider donation of a nerve/muscle biopsy sample upon the death of thisdog, and I will discuss this decision with my veterinarian so that a notation isplaced in the file.Yes: No:
This survey is for the purpose of Leonberger genetic health research; if necessary we may contact you for a phone interview or follow-up questionnaire. We may contact your veterinarianfor additional health information or to obtain a copy of test results mentioned above. The identity of dogs and owners participating in this research will not be revealed.
I have supplied complete and accurate information, to the best of my knowledge.Electronic Signature: Date:
Notice of Privacy Practices
Academic Health Center:
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