WELSH TERRIER HEALTH INCIDENT/DEATH REPORT
The report will
provide owners with a form for documenting health-related incidents and causes
of death in their Welsh Terriers. It will assist the WTCA in its search and
selection process for researchers studying health problems that affect the
breed.
CONDITION/CIRCUMSTANCES: Describe the
occurrence, time of day, signs, symptoms, duration, medications, veterinary recommendations
and outcome. (continue in "OTHER COMMENTS"
if more space is needed)
DATE OF EVENT
OR DEATH:
________________________________
HAVE YOU
NOTIFIED YOUR BREEDER? Yes
[ ]No [
]
AGE
OF YOUR WELSH TERRIER?
Less than 1 yr [ ] 1 to 5 yrs [ ] 5 to 10 yrs [ ] 10 to 15 yrs [ ] Over 15 yrs [ ]
IS YOUR WELSH
TERRIER
Male [ ] Female [ ]
Intact [ ] Spayed [ ] Neutered [ ]
HAS YOUR
WELSH TERRIER EVER BEEN BRED? Yes [ ] No [ ]
WHAT DO YOU
FEED YOUR WELSH TERRIER? (check
all that apply)
[ ] Dry, commercial dog food
[ ] Wet, commercial dog food
[ ] Other e.g. homemade,
organic/natural, prescription, frozen
WHAT
IMMUNIZATIONS HAS YOUR WELSH TERRIER RECEIVED? (check all that apply)
[ ] DHPP – year of last
booster: _______________________
[ ] DHLPP – year of last
booster: ______________________
[ ] Rabies – year of last
booster: ______________________
[ ] Bordetella
– year of last booster: __________________
Others – names
and years: ______________________________________________________
DO YOU USE A
FLEA/TICK PREVENTATIVE? Yes [ ] No [ ]
DO YOU USE AN
ORAL HEARTWORM PREVENTATIVE? Yes [ ] No [ ]
DO YOU USE AN
INJECTABLE HEARTWORM PREVENTATIVE? Yes [ ] No [ ]
IN WHAT PART
OF THE COUNTRY DOES YOUR WELSH TERRIER RESIDE?
North [ ] South [ ] East [ ] West [ ] Other
(name country) _____________________
OTHER
COMMENTS: (include
additional pages if necessary)
I am willing
to be contacted privately to provide further information: Yes [ ] No [ ]
E-mail address:
__________________________________________________
Telephone
number: ____________________________ Day [ ] Evening [ ]
Complete the
form and mail to:
M. Pough
P.O. Box 5786 – Diagnostic Laboratory
New York State College of Veterinary Medicine
Ithaca, New York 14852
Or submit the
form on-line: <home.ec.rr.com/welshealth>
Thank you.