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PBGVCA/BGV CLUB SHORT HEALTH SURVEY PLEASE COMPLETE THIS FORM – IT IS IMPORTANT

WE ESPECIALLY NEED TO KNOW IF YOUR BGV IS HEALTHY! Complete one form for each BGV that you own or that you owned and has died since 2010

Tick or circle each response that applies. Put N/A if question does not apply. If you do not understand this form, please email pmarks1262@aol.com and ask.

TO BE COMPLETED AND RETURNED BY 31 JULY 2016

INFORMATION – ABOUT YOU

Name/s_____________________________ Address __________________________________________________ ____________________________________ County _______________________ Zip/Post Code ____________ Phone __ ___________________________ E-mail Address __________________________________________

Name of Club __________________________________________ National Breed Club Member? Yes No Number of BGVs that live with you: ___________ PBGVs __________ GBGVs

HEALTH SURVEY – ABOUT YOUR BGV Which Breed? PBGV GBGV Sex: MALE FEMALE

Registration Name : ______________________________________ Registration Number __________________ Pet Name: ______________________________________ Date of Birth (day/month/year) ___/____/____ Neutered: Yes No If died since 2010, age at death ________________

WHERE DID YOU GET YOUR BGV (Select option from dropdown menu) Is Breeder a National Club Member Yes No

Imported from Overseas Yes No If Yes which Country ____________________________________________________________

Other (please say) ___________________________________________________

HEALTH TESTING ON THIS BGV: (Date as day/month/year)

Test and most recent test date: Heart _____ Date ________ Hips _____ Date _______ Eyes _____ Date ________

DNA ______ Date ________ POAG Status: Affected Clear Carrier

HAS THIS BGV SHOWN ANY OF THE FOLLOWING CONDITIONS:

1. Birth Defect (cleft palate, liver shunt, hydroencephalitis etc) Y N

2. Blood disorder (clotting issues, low red blood cell count etc) Y N

3. Bone/Joint (arthritis, patella luxation, fractures etc) Y N

4. Cancer/Tumours (Hemangiosarcoma, bone etc) Y N 5. Cardiovascular (Heart murmur, patent ductus arteriosis [PDA] etc Y N

6. Dermatological (hot spots, itching, hair loss etc) Y N

7. Endocrine (overactive/underactive thyroid, diabetes etc) Y N

8. Eyes (cataracts, glaucoma, PLL, POAG, PPM etc) Y N

9. Ears (chronic infections, deafness etc) Y N

10. Gastrointestinal (Pancreatitis, anal glands, obesity etc) Y N

11. Hormonal (Addison’s, Cushing’s etc) Y N

12. Immune Mediated (meningitis, juvenile pain, steroid responsive meningitis) Y N

13. Immune Mediated - craniomandibular osteopathy Y N

14. Liver, Spleen, Gall bladder - (hepatitis, etc) Y N

15. Mouth (gingivitis, teeth etc) Y N

16. Neurological (seizure disorder etc) Y N

17. Reproductive (Male testicular/prostate; Female fertility/whelping disorders, infections, C-section) Y N

18. Urinary (kidney, bladder infections etc) Y N

PLEASE TURN OVER and give details for each YES response. Give details below for each ‘YES’ response

The health problems shown overleaf against each number are just examples. Your details against a number may be for a health problem that is not included under that heading.

Y N

Once completed, remember to SAVE form. Once saved, you can attach to email and send to pmarks1262@aol.com. When using certain web browsers such as Firefox, you may need to download and chose open with Adobe Acrobat to utilize fillable feature.

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List examples of when your BGV has had problems and explain each one. You may use (or attach) your vet’s clinical diagnosis or explain symptoms. Use more paper if necessary.

Remember to write the corresponding number for your details. For example: if you put ‘yes’ for number 11, put #11 in front of your details here. For eye problems (8) please be specific about which condition you are referring to and give date of diagnosis.

Number Additional Information

I AM HAPPY FOR A BGV CLUB HEALTH OFFICER to contact me to resolve any queries on this form Yes No

I UNDERSTAND that this information will be used by the PBGV Club of America and the UK BGV Club for gathering data on the two breeds. This will help determine whether any health problems need researching and help forward planning for funding.

I UNDERSTAND that specific details about me and my BGV will not be published.

I UNDERSTAND that general information on the health of my BGV, health testing or health problems will be included in data shared between Club Health Officers. Afterwards, upholding data requirements, it may also be shared with the Animal Health Trust or other veterinary research organisations, included in any participating country’s breed club literature or website, shared with breed owners worldwide, with the American or British Kennel Club or used responsibly in canine publications where appropriate.

Signature/s _ _________________________________________ Date _______________________

Please post or email this Health Survey Form, with any additional explanatory pages, by 31 July 2016 to: Peter Marks, BGV Club Health Officer, 126 Whitecross, Abingdon, OX13 6BT, England. Or email to pmarks1262@aol.com

Once completed, remember to SAVE form.Once saved, you can attach to email and send to pmarks1262@aol.com.