To update the health status of your dog, who has already been submitted to the study, please complete the form below.

 

If your dog is unaffected with the disease,

please submit a health update annually, even if the dog is still healthy. 

All submissions are confidential.


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DOG INFORMATION

Breed        

Dog's Registered Name:    Call Name:

AKC Registration #:           

Sex  

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

Sire's Registered Name:  

Dam's Registered Name:

     

Disease Status:     If Other, please specify

Comments regarding the dog's overall health (include any autoimmune disorders):

If dog is deceased, age at death:                years                months

Cause of death:

 

If your dog has been diagnosed with Addison's disease, please fill out the following information:

How was Addison's disease diagnosed? (i.e., ACTH test) 

        Age of dog at diagnosis:     years       months

Please indicate the dog's electrolyte levels if known:

If the dog is spayed or neutered, was the diagnosis prior to or after the spay or neuter? 

Symptoms of Addison's disease:

Was the dog on any steroid treatment prior to diagnosis? 

    If Yes, explain:

If you know of relatives with Addison's disease, include the relationship to your dog and names of the relatives if known:

 

If your dog has been diagnosed with Epilepsy, please fill out the following information:

How was Epilepsy diagnosed?

Age of dog at diagnosis:    years    months

What is the seizure status of the dog:           

At what age was the first seizure: years    months

If the dog is spayed or neutered, was the diagnosis prior to or after the spay or neuter? 

Symptoms of Epilepsy (describe a typical seizure in detail):

Has your dog ever had any type of head trauma? 

    If Yes, explain:

 

If you know of relatives with Epilepsy, include the relationship to your dog and registered names of the relatives if known:

 

OWNER INFORMATION

 

First Name    Last Name  

 

Address  

 

City                State/Province (abbreviate)   

 

Zip/Postal Code           Country (if not USA)

 

Phone (area code + number)  

 

E-Mail

 

Check here if your contact information has changed:  

 

Comments:

Please Note:  This update is for research only - all submissions are confidential.

If you would like to send a copy of your dog's pedigree, please include your name and send it 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