CMD Health Survey

Caucasian Mountain Dog
Health Survey

Name: EMail:

Address:

Phone:

Dog's Name & Reg#:

Dog's sex:
male intact
male neutered
female intact
female spayed

Dog's date of birth or age:

Sire's Name & Reg#:

Dam's Name & Reg#:

Name of breeder:

Is this dog living?
Yes
No

If this dog has died, what was the cause of death and dog's age?

Check all eye problems this dog has had:
Cherry eye
Chronic conjunctivitis
Blindness
Entroprian
Ectroprian
PRA

List other eye problems:

Check all ear problems this dog has had:
Chronic ear infections
Deafness
Hearing impaired

List other ear problems:

Check all skin problems this dog has had:
Chronic skin infections
Demodectic Mange
Allergies
Non-Specific Dermatitis
Pyoderma (puppy strangles)
Seborrhea

List other skin problems:

Check all heart problems this dog has had:
Cardiac failure
Cardiomyopathy
Valvular
Murmurs
Shunts

List other heart problems:

Check all musculoskeletal problems this dog has had:
Hip Dysplasia
Arthritis
Dwarfism
Panosteitis (pano)
Osteochondritis Dissecans (OCD)
Patellar Luxation

List other musculoskeletal problems:

Check all respiratory problems this dog has had:
Chronic respiratory infections
Pneumonia
Chronic Tracheobronchitis
Chronic Sinusitis
Asthma

List other respiratory problems:

Check all urinary system problems this dog has had:
Chronic Renal Failure
Acute Renal Failure
Tumors
Chronic infection
Urolithiasis

List other urinary system problems:

Has this dog had its hips evaluated by x-ray?
Yes
No

If yes, by whom?
OFA
Penn-Hip
Veterinarian
Other

What was the hip rating?

Does this dog exhibit any signs of hip dysplasia? Explain:

Has this dog ever had Bloat?
Yes
No

List other gastroenteric problems:

Has this dog ever been diagnosed with Cancer?
Yes
No

If yes, what type and area of body was affected?

Has this dog had its Thyroid checked?
Yes
No

Results?:
Normal
Hypothyroidism (low)
Hyperthyroidism (high)

Check all Blood problems this dog has had:
Anemia
Von Willebrand's Disease
Autoimmune Hemolytic Anemia
Hemophilia

List other Blood problems

Check all Deficiencies this dog has had:
Hormone
Diabetes
Addison's Disease
Cushing's Disease
Pancreatitis
Pituitary

Has this dog ever been bred?
Yes
No

If yes, how many litters resulted?

Check all FEMALE reproduction problems:
Irregular heats (Long cycle)
Irregular heats (Short cycle)
Silent heats
Refusal to breed
Failure to conceive
Split heats

Check all Pregnancy related problems:
False Pregnancy
Abortion/Miscarriage
Premature births
Caesarean Section
Pyometra
Mastitis

List other FEMALE reproduction/pregnancy problems:

Check all MALE reproduction problems:
Defective sperm
Sterility
Impotence (inability to mate)
Lacks interest in mating
Prostate Disease
Penis abnormality
Check Testicular related problems:
Unequal in size
Cryptorchidism (1 testicle)
Cryptorchidism (Both testicles)
List other MALE reproductive problems:

List all other health related problems not specified herein:

Thank you for your participation in the survey. Your comments are welcomed.

Caucasian Mountain DogHealth Survey

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Caucasian Mountain Dog
Health Survey