Please note that underlined and bolded fields must be completed before your submission will be accepted.

Dog Information:

Breed:   Choose Bearded Collie Great Dane Leonberger Portuguese Water Dog Standard Poodle West Highland White Terrier

Dog’s Registered Name:      Call Name:

AKC Registration #:  

Date of Birth (i.e., mm/dd/yy):     Date of Death (i.e., mm/dd/yy):

Coat Color:           Sex:           Choose Female - Spay Male - Neuter Female Male

                                                                                            Paternal Grandsire Registered Name:

Sire's Registered Name:           

                                                                                            Paternal Granddam Registered Name:

      Sire's AKC Registration #:

                                                                                            Maternal Grandsire Registered Name:           

Dam's Registered Name:            

                                                                                            Maternal Granddam Registered Name:

      Dam's AKC Registration #:

If you could, please send a copy of your dog's pedigree with your name to the following address:

Oberbauer Lab

Canine Genetic Analysis Project (CGAP)

Department of Animal Science

University of California

One Shields Avenue

Davis, CA 95616-8521

Disease Information: 

Addison’s Disease: Choose Yes No     Age at Diagnosis:  years          months 

1. What Addison’s disease symptoms prompted you to go to the vet?

2a. What specific test was used to determine the diagnosis of Addison's disease? (please be specific, ie., ACTH Stimulation test)

2b. Please mail copies of medical records pertinent to diagnosis and blood test results at the time of diagnosis.  You can fax the information to the Oberbauer Lab, Department of Animal Science 530-752-0175 or mail to Oberbauer Lab, Canine Genetic Analysis Project (CGAP), Department of Animal Science, University of California, One Shields Avenue, Davis, CA 95616-8521.

3. Was the dog on any type of steroid treatment prior to diagnosis of Addison's disease?   Choose Yes No

4. If the dog was spayed or neutered, was Addison’s disease diagnosed prior to or after spay or neuter?  Choose Prior to After

5. Include any details of known relatives with Addison’s disease (include registered names if known):

6. General comments regarding animal’s health. Please include ANY health issues associated with the dog, including hypothyroidism or any other type of autoimmune disorder:

7. List any medications (including steroids) the dog has taken over its lifetime.  Please denote if they were given pre or post Addison diagnosis.

Owner Information:

First Name    Last Name    

Address   

City                State/Province (abbreviate)    

Zip/Postal Code           Country (if not USA)

Phone (area code + number)    

E-Mail

   Thank you for participating!