In order to help us determine the health problems and cause of death of the Bernese Mountain Dog, please take a few moments to print this form, complete it and mail it in to the address below : Sondage Santé / Health Survey a/s Martha Millas 44 Bl St-Joseph app.2 Lachine, Québec H8T 1R2

Owner name: (Mr./Mrs)
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Address:
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City/Prov.:
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Country :
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Postal code/Zip code :
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Téléphone # :
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Email:
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This dog's breeder :
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Kennel name:
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Dog's registered name :
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Date of birth :
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CKC registration #:
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Sire's Reg. name:
_______________________________CKC reg.#:____________________
Dam's reg.name:
________________________________CKC reg.#_____________________

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Is this dog dead ?  yes   No

Age of death ?_____________________

Was autopsy performed to determine cause of death ?__________________________

If euthanized, reason for doing so ?_____________________________

Has this dog ever been bred ?_____________________________

Number of litters ?____________________________________

Spayed/neuter ?______________Age done ?_______

1. X-Rays

Has this dog been X-Rayed for Hip Dysplasia ?      Age done : GDC #:________________ OFA # :___________________PennHip :_________________

2.Skeletal

Hip Dysplasia [Age:   ] Elbow Dysplasia [Age:   ] Osteochondritis Dessicans(OCD)[Age:   ] Panosteitis [Age:    ] Patellar Luxation  [Age:   ] Arthritis [Age:    ] Spinal Myelopathy [Age:    ] Cervical Vertebral Instability (Wobbles) [Age:   ] Other spinal problems [Age:    ] Dwarfism Other Description:_______________________________ [Age:   ]

3. Eyes and Ears

Have this dog's eyes been examined by a specialist ?_______________   [Age:    ] Entropion [Age:   ] Ectropion [Age:   ] Cataracts [Age:   ] Persistent Pupilary Membrane [Age:   ] Other Description:_________________________ [Age:   ] Deaf [Age:   ] Hearing Impared[Age:    ] Chronic Ear Infections [Age:    ] Other Description:__________________________ [Age:   ]

4.Skin

Chronic Hot Spots [Age:    ] Seborrhea [Age:    ] Demodectic Mange [Age:    ] Persistent Staph Infection (Pyoderma) [Age:    ] Food Allergies [Age:    ] Other skin problems Description:________________________ [Age:    ]

5. Cancer

Bone Tumors : Osteosarcoma [Age:    ] Chondrosarcoma [Age:    ] Fibrosarcoma [Age:    ] Liposarcoma [Age:    ] Other Malignant Histiocytosis [Age:    ] Mastocytoma [Age:    ] Lymphosarcoma [Age:   ] Leukemia [Age:   ] Other cancer Description:_________________________[Age:    ]

6. Blood Problems

Anemia [Age:    ] Hemophelia [Age:    ] von Willebrand Disease [Age:    ] Autoimmune Hemolytic Anemia [Age:   ] Other Description:________________________ [Age:    ]

7.Hormone Deficiencies

Diabetes [Age:   ] Pancreatitis [Age:    ] Addison's Disease [Age:    ] Hypothyroidism [Age:   ] Hyperthyroidism [Age:  ] Pituitary [Age:    ] This dog has had Thyroid tests( T3-T4 )?________________________[Age:    ]

8. Kidney Problems

Cystittis ( bladder infection) [Age:    ] Congenital Kidney Disease [Age:    ] Chronic Interstitial Nephritis [Age:    ] Stones [Age:   ] Other Kidney Disease [Age:   ]

9.Heart problems

Valves [Age:    ] Stenosis(aortic) [Age:    ] Murmurs (Age:   ) Congestive Heart failure [Age:    ] Cardiomyopathy [Age:    ] Patent Ductus Arteriosis [Age:   ] Septal Defect [Age:    ] Heart Worms [Age:   ] Other Heart problems Description:_______________________ [Age:    ]

10. Reproductive Problems

Females: Irregular Heats     Months between heats :_________ [Age:    ] Refusal to accept male [Age:   ] Failure to conceive [Age:    ] Fetal Mortality [Age:    ] Vaginal Infection [Age:   ] Pyometra [Age:   ] Mastitis [Age:    ] Difficulty Whelping [Age:   ] Caesarean Sections  How often :__________[Age:   ] Males : Lack of interest in female [Age:   ] Impotence [Age:    ] Sterility [Age:   ] Anomalie du sperme [Age:   ] Abnormality of Testicules [Age:   ] Genital Infection [Age:   ] Prostatitis [âge:   ] Other reproductive problems Description:____________________________ [Age:    ]

11.Temperament

How would you describe your dog's temperament? Very shy Timid Reserved Confident Protecteur Aggressive Has this dog ever bloated ?_________________ Age________ How often__________________ Did this dog die of Bloat ?_______________ Age___________ Has this dog ever had seizures ?_______________Age____________

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