5a. Bone and skeletal
Any problems with hips?
Yes
No
Has the hips been x-rayed?
Yes
No
Hip dysplasia right
A
B
C
D
E
Hip dysplasia left
A
B
C
D
E
Any problems
with elbows?
Yes
No
Has the elbows been x-rayed?
Yes
No
Elbow dysplasia right
Elbow dysplasia left
Any problems with the knees?
Yes
No
Has the knees been checked?
Yes
No
Patella right
Patella left
Any problems with other bone and skeletal?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5b. Eyes
Has the eyes been checked?
Yes
No
Any problems or diseased with the eyes?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5c. Teeth
Bite:
Choose:
Scissor bite
Over bite
Under bite
Missing teeth
Yes
No
Which teeth are missing?
Other problems with the mouth or teeth?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5d. Skin and coat
Any skin or coat problems?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5e. Allergies
Any allergies?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5f. Ears
Any ear problems?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
Deafness
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5g. Diseases of internal organs
Any problems with internal organs?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5h. Diabetes
Has the dog diabetes
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5i. Autoimmune disease
Has the dog autoimmune disease?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5j. Hernia
Has the dog had hernia?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5k. D iseases of respiratory organs
Has the dog had any diseases of respirotory
organs?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5l. Cancer or other tumors
Has the dog cancer or other tumors?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
5m. Epilepsy, seizures
Has the dog epilepsy?
Yes
No
Age of onset?
Specify
What was done? Any health care?
Yes
No
Any other seizures?
Yes
No
Specify
5n. Hypothyroidism
Has the dog hypothyroidism?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
Has there been done any tests for
hypothyroidism for example TgA-test?
Yes
No
Test results
6. Health problems related to sex
6a. Females
Has the female some of these:
False pregnancy
Yes
No
Uterine inflammation
Yes No
Reproduction problems
Yes No
Difficulty whelping
Yes No
Puppies died (fading puppy)
Yes
No
Other information
Has the female had any other problems or diseases related to sex?
Yes No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
Any health problems with the puppies?
Yes
No
What kind of problems?
6b. Males
Has the male some of these:
Cryptorchidism
Yes
No
Prostate problems
Yes
No
Reproduction problems
Yes
No
Any other?
Has the male had any other problems or diseases related to sex?
Yes
No
Age of onset?
Specify
Diagnosis
What was done? Any health care?
7. OTHER DISEASES
Has the dog other diseases?
Yes
No
Specify
Diagnosis
What was done? Any health care?
8. CHARACTER
Temperament, behavior
Very active
Yes
No
Moderately active
Yes
No
Peaceful
Yes
No
Scared
Yes No
Brave
Yes No
Uncertain
Yes No
Well balanced
Yes No
Open to other dogs
Yes No
Agressive to strange dogs
Yes No
Bitten strange dog
Yes No
Over sexual
Yes No
Open to people
Yes No
Agressive to people
Yes No
Bitten a human
Yes No
Kind to children
Yes No
Shyness
Yes No
Fear aggression
Yes No
Training:
Willing to please
Yes
No
Easy to train
Yes
No
Strong play drive
Yes
No
Strong work drive
Yes
No
Easily surrending
Yes
No
Challenging behavour, testing his/her
boundaries
Yes
No
Willing to apport
Yes
No
Willing to swim
Yes
No
Natural hunting instinct
Yes
No
Noise phobias
Yes
No
Mindless barking
Yes
No
Guarding behavior
Yes
No
Extreme guarding behavior
Yes
No
Separation anxiety
Yes
No
Any other?
9. OTHER INFORMATION
Other
information connecting to my dogs health and character