Glen
of Imaal Terrier Club of America, Inc.
2004
Breed Health Survey
Please
use one survey per dog. If you
cannot make copies, please let me know and I will mail additional forms, or
you can go to the club’s website at www.glens.org and
download one from there.
Personal
History
Length
of time in breed: 1-5
yrs_____6-10 yrs_____11-15 yrs_____over 15
yrs_____
Primary
interest (check all that apply):
Agility____Breeder____Companion
Pet____Earthdog____Exhibitor____ Obedience____Therapy____Working/Hunting____Other_____________
Name
& Address (optional)__________________________________________________
Registered
Name of Dog (optional)____________________________________________
Call
name (optional)____________________
How
many Glens currently owned _____Sex
Male_____Female_____
__________________________________________________________________________
If
you have ever had a Glen that died, please list below:
1.
Cause
of death_____________________________________
2.
Age
at death_______________________________________
3.
Autopsy
performed Yes____No____If
yes, what were the results____________________________________________
____________________________________________________________________________
Input
Is
this Glen Intact____Neutered____Spayed____
If
neutered or spayed, at what age was this procedure performed ______
Does
this Glen have annual vaccinations done
Yes____No____
Do
these vaccinations include (check all that apply)
Distemper____Adenovirus____Parainfluenza____Parvovirus____Leptospira____
Coronavirus____Lyme____Rabies____Bordetella____Other_________________
Has
this Glen ever had an adverse reaction to a vaccine
Yes____No____If
yes, please
explain_______________________________________________________________
If
you do not vaccinate your Glen, do you titer
Yes____No____
Do
you feed a commercial dog food
Yes____No____What
brand/type_____________
Do
you feed a raw diet Yes____No____
Any
supplements given Yes____No____
If so, what___________________________
Do
you use heartworm preventative
Yes____No____
If so, what__________________
Any
adverse reactions Yes____No____If
yes, please explain______________________
Do
you use a flea/tick preventative
Yes____No____If
yes, what brand_________________
Any
adverse reactions Yes____No____If
yes, please explain_______________________
Do
you worm this dog Yes____No____If
yes, what type/brand of wormer and how
often____________________________________________________________________
Any
adverse reactions Yes____No____If
yes, please explain________________________
Has
this Glen ever been administered anesthesia
Yes____No____
Were
there any adverse reactions
Yes____No____If
yes, please explain________________
Type
of anesthesia, if known______________________________
____________________________________________________________________________
Health
Current
age of this Glen _____
Has
this Glen been diagnosed with any of the following condition(s)
Cancer
Yes____No____If
yes, what type___________________________Age of
Onset_____
Age
of Death______Treatment
given_______________________________________________
Progressive
Retinal Atrophy (PRA)
Yes____No____If
yes, at what age_____
Do
you have this Glen tested yearly for PRA
Yes____No____
Any
other eye condition Yes____No____If
yes, what type and at what
age_________________________________________________________________________
Has
this Glen experienced any joint problems
Yes____No____If
yes, please explain what type and any treatment/surgeries
done_________________________________________________
Has
this Glen experienced any heart conditions
Yes____No____If
yes, please explain what type and any treatment, medications,
etc____________________________________________
Has
this Glen experienced any of the following conditions.
Please check all that apply.
Bladder____Kidney____Liver____Lung____Pancreas____Prostate____
If
yes, please explain___________________________________________________________
Any
other internal organ problems
Yes____No____If
yes, please explain__________________
Has
this Glen experienced any skin conditions
Yes____No____If
yes, please describe and what treatment/medications were
given_________________________________________________
Was
treatment successful
Yes____No____
Has
this Glen experienced any allergies
Yes____No____If
yes, please describe and what treatment/medications were
given_________________________________________________
Was treatment successful
Yes____No____
Has
this Glen experienced any back problems
Yes____No____If
yes, please explain_________
Has
this Glen experienced any temperament problems
Yes____No____
Aggression_____Shyness_____Other______________________
Has
this Glen experienced any seizure problems
Yes____No____If
yes, please describe and indicate what type of medication is being
used______________________________________
How
would you rate the overall health of this Glen
Excellent____Very good____Good____Average____Poor____
If
this Glen suffered from any ailment/disease not covered in this survey, please
list below
____________________________________________________________________________
____________________________________________________________________________
Reproduction
For
Male Glens
Please
check below any that apply to this Glen
Abnormal
Semen____Congenital defects____Cryptorchidism____Lack
of Libido____
Lack
of Semen____Monorchidism____Testicular atrophy____Other______________
For
Female Glens
Please
check below any that apply to this Glen
Abnormal
puppies____Cleft palates____Hydrocephalus____Incomplete
abdominal closure____
Failure
to walk (swimmers)____Chronic false pregnancies____Difficulty
in whelping____
Failure
to carry to term____Failure to conceive____Insufficient
milk____Irregular heat cycles__
Mastitis____Poor
mothering instinct____Primary uterine inertia____Pyometra____
Sizes
of litters____C-Section____Other____________________________________
____________________________________________________________________________
Please
list three diseases/ailments, in order of importance, that
you consider to be the most important in this breed
1._________________________
2._________________________
3._________________________
If
you require more space to answer/explain on any of the above-mentioned
questions, please attach a separate sheet of paper to this survey.
Please
return completed survey(s) to:
Maura High, Chairperson
GITCA Health Committee
If
you have questions, please contact any of the following Health Committee
Members
Maura
High coleraine@centurytel.net
-
816-296-7030
Peg
Carty
carty@ntelos.net
- 540-885-4513
Ara
Lynn
liberty@glenterriers.com
-
603-878-3552
Mary
McDaniel, DVM anatoliandoc@cs.com
- 863-293-0183