Microsoft word - kbtf health survey may 5 2010 final

Health Survey 2010
• Please fill out information on each Kerry Blue Terrier
• To help maintain confidentiality, do not include that you have owned in the last five (5) years.
personal identifiers or put a return address on the • Provide information on each dog separately. Make additional copies of this form, or print more from • Return the completed forms to our independent http://www.kerryblues.info by clicking on “Health.” collector, Marit Marino, by August 31, 2010, using
• For each dog, enter the appropriate Disease Code for each disorder that has affected the dog during • Your completion of this survey is one step forward its life. Comments about the method of diagnosis in helping future generations of Kerries avoid • Please report dogs who have had no health problems; • Your cooperation is important and
it is very important that healthy dogs be included. appreciated!
General Information
Country of Residence: ______________
Length of time in breed:
State or Province: __________________ 1–5 years 6–10 years 11–15 over 15 years
Do you believe that the Kerry Blue Terrier is a healthy breed?
Total # of Kerries owned: _________
Do you regularly participate in any of the following? (check al that apply):

Date of birth:___ ___ ___ Date of death (if applicable): ___ ___ ___ If spayed/neutered, age at spaying/ neutering:___________ If bred, #of litters sired/whelped:_________ Parasite prevention (fleas, ticks, heartworm): If yes, please list products used:_____________________ # of pups per litter (list each litter separately): Health Screening Tests (e.g. OFA/PennHip x-rays, CERF eye certification exam or equivalent, etc.) Age of Onset Comments (Use additional page if desired) Additional copies of the Kerry Blue Terrier Foundation’s Health Survey 2010 may be downloaded from http://www.kerryblues.info/. Click on “Health,” then “Health Survey 2010.” Health Survey 2010—continued

Date of birth: ___ ___ ___ Date of death (if applicable):___ ___ ___ If spayed/neutered, age at spaying/ neutering:___________ If bred, #of litters sired/whelped:_________ Parasite prevention (fleas, ticks, heartworm): If yes, please list products used:_____________________ Health Screening Tests (e.g. OFA/PennHip x-rays, CERF eye certification exam or equivalent, etc.) Age of Onset Comments (Use additional page if desired) Date of birth: :___ ___ ___ Date of death (if applicable):___ ___ ___ If spayed/neutered, age at spaying/ neutering:___________ If bred, #of litters sired/whelped:_________ Parasite prevention (fleas, ticks, heartworm): If yes, please list products used:_____________________ Health Screening Tests (e.g. OFA/PennHip x-rays, CERF eye certification exam or equivalent, etc.) Age of Onset C o m m e n t s (Use additional page if desired) Additional copies of the Kerry Blue Terrier Foundation’s Health Survey 2010 may be downloaded from http://www.kerryblues.info/. Click on “Health,” then “Health Survey 2010.” Disease Codes
Heart Problems
506 Ivermectin + Pyrantel (Heartgard Plus) Autoimmune and Immune Problems
102 Thyroid (thyroiditis, hypothyroidism) 100 4 Murmers (specify in “Comments”) 1 0 0 5 Other (specify in “Comments”) 510 Milbemycin oxime + lufenuron (Sentinal) Infectious Disease
1103 Bacterial (specify in “Comments”) 1104 Viral (specify in “Comments”) 1 1 0 5 Fungal (specify in “Comments”) 5 2 0 Other drugs (specify in “Comments”) 115 Neurologic (degenerative myelopathy) Toxicity
1 1 6 Other (specify in “Comments”) Blood Problems
1112 Other (specify in “Comments”) Liver/Spleen Problems
5 2 5 Plants (specify in “Comments”) 526 Other toxins (specify in “Comments”) Ear Problems
6 0 5 Other (specify in “Comments”) 211 Other (specify in “Comments”) 1209 Other (specify in “Comments”) Endocrine Problems
Muscle Problems
705 Prostatic disease (specify in 1307 Other (specify in “Comments”) 7 0 8 Other (specify in “Comments”) Mouth and Tooth Problems
Eye Problems
801 Distichiasis (eyelashes touching eye) 802 Entropion (eyelid turns away from eye) 804 Cataracts (specify type in “Comments”) 1406 Halitosis (bad breath or mouth odor) 806 Keratoconjuntivitis sicca (KCS, dry eye) 315 Bladder (transitional cell carcinoma) 1409 Wry mouth (one side of jaw longer than 811 Other (specify in “Comments”) 320 Other (specify in “Comments”) 1410 Other (specify in “Comments”) Gastrointestinal Tract Problems
Dietary Problems
Neurological Problems
401 Food hypersensitivity (specify in 1503 Progressive neuronal abiotrophy (PNA) Drug or Toxicity Reactions
907 Colitis, chronic (inflammatory bowel Drug Reactions
disease) (specify type in “Comments”) 909 Megaesophagus (esophageal dilatation) 1509 Other (specify in “Comments”) 912 Other (specify in “Comments”) —Disease Codes continued on next page
Disease Codes—continued
Nonmalignant Warts, Cysts, and Lumps
Skeletal/Joint Problems
Temperament Problems
1806 Other (specify in “Comments”) 1607 Hemangioma (benign blood vessel tumor) Skin and Haircoat Problems
2008 Unstable (erratic or unpredictable) 1609 Spicules (abnormally thick, malformed 2010 Other (specify in “Comments”) Tissue Deformities
1610 Other (specify in “Comments”) 1904 Hot spots (significant or recurrent) 1905 Reproductive Problems
1906 Chewing or biting at skin, coat (persistent) 1701 Pyometria (severe uterine infection) 2104 Other (specify in “Comments”) Urinary Tract Problems
2201 Cystitis (recurrent bladder infections) 1911 Mang e, other (specify in “Comments”) 2202 Vaginitis (recurrent vaginal infections) 1912 Pemphigus (specify in “Comments”) 2203 Bladder stones (specify in “Comments”) 2204 Kidney disease (specify in “Comments”) 2205 Kidney stones (specify in “Comments”) 2209 Other (specify in “Comments”) 1713 Cryptorchid (undescended testicles) Vaccine Reactions or Failures
1714 Monorchid (single undescended testicle) 2301 Vaccine reactions (specify vaccine type in 1921 Other (specify in “Comments”) 1716 Other (specify in “Comments”) 2 30 2 Vaccine failure (specify type of vaccine in “Comments” that failed to produce protection) 1st CLASS
Marit Marino
4167 Huckleberry Drive
Concord, CA
94521 USA

Source: http://www.kerryblues.info/HEALTH/2010HealthSurvey.pdf