CHIC DNA Repository
Health Survey
Owner Name______________________________________Dog Call Name___________________
Has this dog ever been diagnosed with any of the following health issues?
For each section you answer with a yes, please fill out the rest of the section. If you answer no to any section, skip to the next section.
Cancer/Tumors Yes No
Fibrosarcoma
Hemangiosarcoma
Leukemia
Liver cancer
Lymphatic cancer
Lymphoma
Mammary cancer
Mast cell tumor
Melanoma
Muscle cancer
Osteosarcoma
Ovarian cancer
Pancreatic cancer
Pituitary tumors
Sebaceous gland tumors
Squamous cell tumor
Testicular cancer
Other _______________________________
Gastrointestinal Disorders Yes No
Bloat
Colitis
Inflammatory bowel disease
Megaesophagus
Other _______________________________
Cardiac Disorders Yes No
Arteriosclerosis
Cardiomyopathy
Congestive heart failure
Degenerative valve disease
Heart murmur
Mitral valve defect
Pulmonic stenosis
Subaortic stenosis
Tricuspid valve defect
Other _______________________________
Respiratory Disorders Yes No
Collapsed trachea
Elongated soft palate
Stenotis nares
Other _______________________________
Eye Disorders Yes No
Cherry eye
Corneal dystrophy
Corneal ulcer
Distichiasis
Dry eye
Entropian/ectropian
Glaucoma
Juvenile cataracts
Optic nerve hypoplasia
Progressive retinal atrophy
Retinal dysplasia
Retinal folds
Senile cataracts
Other _______________________________
Ear Disorders Yes No
Chronic ear infection
Deafness
Other _______________________________
Neurologic/Muscular Disorders
Yes No
Ataxia
Atlanto axial subluxation
Caudea equina syndrome
Epilepsy
Fibrocartilagenous embolis
Intervertebral disc disease
Lu