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       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 NoIf 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  YesNoIf yes, please explain 

Has this Glen experienced any temperament problems 

YesNo

Aggression,Shyness,

Other 

Has this Glen experienced any seizure problems 

YesNo

If yes, please describe and indicate what type of medication is being used 

How would you rate the overall health of this Glen

            ExcellentVery goodGoodAveragePoor

If this Glen suffered from any ailment/disease not covered in this survey, please list

 

 

Reproduction

For Male Glens  
Please check 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  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,