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  Home > VBS Faculty > James R. Mickelson > Canine And Equine Genetics Laboratory > Leonberger Polyneuropathy > Online Health Update
 

Online Health Update

University of Minnesota
Inherited Polyneuropathy: Genetic Studies



Dog Information

Registered Name:

Call Name:

 Registration number:

Birthdate:


Breed:

Sire:

Dam:

Date of Death:

Sex:
Male Female Intact Neutered/Spayed
 


Owner Information


Owner Name
Address
City,State,Zip
Daytime Phone
Evening Phone:
Fax:
Email:


Alternate Contact:
Address:
City, State, Zip:
Daytime Phone:
Evening Phone:
Fax:
Email:

 

Has this dog been diagnosed as being affected with polyneuropathy
and laryngeal paralysis. If yes, indicate how and by whom (biopsy,
nerve conduction study, etc). If available, please attach a copy
of the biopsy report.
Yes: No:

Veterinarian who made the diagnosis
 

Name:
Clinic:
Street Address:
City,State,Zip:
Country:
Phone:
Fax:
Email:

Current Veterinarian, if different
 

Name:
Clinic:
Street Address:
City,State,Zip:
Country:
Phone:
Fax:
Email:

Clinical Signs
 

Exercise Intolerance:
Yes:  No:
Age first noticed:

Laryngeal Paralysis
 

Changes in bark quality:
Yes:  No:
Age first noticed:


Difficulty breathing:
Yes:  No:
Age first noticed:


Difficulty swallowing:
Yes:  No:
Age first noticed:


Has your dog had a tieback surgery?
Yes:  No:
Age at time of surgery:


Feel free to elaborate on your answers to the above questions:

Polyneuropathy
 

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:


Muscle atrophy
Yes:  No:
Age first noticed:


If yes, which limbs were involved?
Front Right:
Front Left:
Rear Right:
Rear Left:

Feel free to elaborate on your answers to the above questions:

Does your dog have a history of (check all that apply):
 

Cancer (specify type below)
Diabetes
Arthritis
Heart Disease
Hypothyroidism
Hip Dysplasia
Spinal Disc Disease
Seizures
Torn Cruciate Ligament


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.


Please list related dogs that are possibly affected with
laryngeal paralysis or polyneuropathy (registered name if known):


I am willing to provide additional blood samples if needed for research.
Yes: No:

I am willing to consider donation of a nerve/muscle biopsy sample upon the death of this
dog, and I will discuss this decision with my veterinarian so that a notation is
placed in the file.
Yes: No:

I submit this survey for the purpose of research; I agree to a
phone interview or questionnaire if needed; I agree for my veterinarian to be
contacted if necessary; I understand that the identity of dogs and owners
participating in the research will not be revealed; and I have supplied
complete and accurate information, to the best of my knowledge.

Signature:
Date:


 

 



 

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