IWC Windsprite Health Survey

IWC Windsprite Health Survey
Thank you for participating in the IWC Health Survey. It is lengthy so that we get as complete a picture as possible of the health of our breed. Please be as specific and detailed as possible when describing conditions. We appreciate your time and consideration to provide the most complete information possible. Please fill out this survey for both living and deceased Windsprites.”
OWNER INFORMATION
Date *

Month Day Year
mm-dd-yyyy or use calendar button
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State/Province

Zip/Postal Code Country
Best Phone Number *

Area Code Phone Number
Email *
example@example.com
Are you a current IWC Club member?

YES NO DON'T KNOW
Dog Information: Information for this section can be found on your dog’s IWC Registration Certificate
Registered Name of dog
(if known)
Registration Number
(if known)
Call name *
Variety *

Longhair Windsprite Smooth Windsprite Percentage Windsprite
Date of Birth
(if known)
Sex *

Intact Male Neutered Male Intact Female Spayed Female
If spayed or neutered, at what age?
(If known)
Color/Pattern
(as described on registration certificate)
Weight (lbs)
Height at withers (inches)
(If known)
Dam Registered Name
(If known)
Dam Call Name
(If known)
Dam Registration Number
(If known)
Sire Registered Name
(If known)
Sire Call Name
(If known)
Sire Registration Number
(If known)
MDR1 status

Normal/Normal (Normal) N/N (+/+) A Normal/Mutant (Carrier) N/M (+/-) B Mutant/Mutant (Affected) M/M (-/-) C Unknown
CEA status

Normal/Normal (Normal) N/N (+/+) A Normal/Mutant (Carrier) NM (+/-) B Mutant/Mutant (Affected) M/M (-/-) C Unknown
Health Information
OFA/CAER Eye Exam (Date most recent)
OFA/CAER Eye Exam Result

Normal Abnormal
If OFA/CAER Eye Exam Abnormal, what was the reason?
OFA Cardiac Exam (Date most recent)
OFA Cardiac Exam Method

Auscultation (Basic) Echo (Advanced)
OFA Cardiac Exam Results

Normal Abnormal
If OFA Cardiac Exam Abnormal, what were the findings?
Has your dog ever been DIAGNOSED BY A VETERINARIAN with any of the following? (You may check multiple conditions.)

If yes to any, please include the following information in the comments box at the end of each section:

1. Initial symptoms?

2. At what age did the condition begin?

3. What tests were done for diagnosis?

4. Did the condition(s) resolve or are they ongoing?

5. Is the dog on medication for the condition(s)?

6. Does the dog require a special diet due to health reasons? (If yes, please elaborate.)

7. Additional comments?
Allergies & Sensitivities

Food Allergy Food Sensitivity Seasonal/Environmental Allergy Season/Environmental Sensitivity
If 'yes' to any of the above, how did the allergy or sensitivity manifest? (Itchy, hair loss, GI symptoms, respiratory?) Please elaborate.
Aural

Unilateral Pigment Associated Deafness Bilateral Pigment Associated Deafness Unilateral Non-pigment associated Deafness Bilateral Non-pigment associated Deafness Other Ear Disease/condition (please elaborate)
If yes to any of the above, please elaborate.
Cancer

Hemangiosarcoma Lymphoma Mast cell tumor Osteosarcoma Other cancer or tumor (please elaborate)
If yes to any of the above, please elaborate.
Cardiac

Heart Murmur (Mitral, Tricuspid, or other?) Valvular Disease (Mitral, Tricuspid, or other?) Aortic Stenosis Patent Ductus Arteriosis Ventricular Septal Defect Heartworm Disease Congestive heart failure Dilated Cardiomyopathy Other cardiac disease/disorder (please elaborate)
If yes to any of the above, please elaborate.
Endocrine

Addison's Disease Atypical Addison's Disease Cushings Disease Hypothryoidism Diabetes Other Endocrine Disease/Disorder (elaborate below)
If yes to any of the above, please elaborate.
Gastro-Intestinal & Urinary

Pancreatitis (Acute) Pancreatitis (Chronic) IBS (Irritable Bowel Syndrome) IBD (Inflammatory Bowel Disease) Kidney Disease Bladder or Kidney Stones Prostatitis Liver Disease Frequent Urinary Tract Infections Urinary Incontinence Frequent diarrhea Frequent constipation Frequent nausea or vomiting Hunched back/painful abdomen Carsickness
If yes to any of the above, please elaborate.
Immune & Blood Disorders

Anemia AIHA/IMHA (Autoimmune Hemolytic Anemia/ Immune Mediated Hemolytic Anemia) Thrombocytopenia Other Autoimmune disease/disorder (please elaborate)
If yes to any of the above, please elaborate.
Neurologic

EIH (Exercise Induced Hypothermia) Epilepsy Neurologic symptoms such as weakness, paralysis, or instability due to Herniated Disc or Intervertebral Disc Disease Vestibular Disease Other neurologic disease/condition (please elaborate)
If yes to any of the above, please elaborate.
Ophthalmic

CEA (Collie Eye Anomaly/Choroidal Hypoplasia) Only note if actually physically symptomatic, not if merely genetically affected Cherry Eye Luxated Lens Ectropion/Entropion Age related cataracts Juvenile or early onset cataracts Glaucoma Other eye diseases/conditions (please elaborate)
If yes to any of the above, please elaborate.
Oral

Periodontal Disease Endodontic Disease Unerupted Teeth Overbite Underbite Broken, chipped, or fractured tooth Other dental problem/disease (please elaborate)
If yes to any of the above, please elaborate.
Orthopedic

ACL/CCL Injury Hip Dysplasia Elbow Dyslasia Luxating Patella (if diagnosed as a juvenile, did it resolve?) Cervical or spinal disc disease Other orthopedic disease/condition (please elaborate)
If yes to any of the above, please elaborate.
Has your dog ever broken a bone? If so, which bone? At what age? How did the break occur? Did it require surgical repair? DId it heal successfully?
Reproductive

Pyometra Mastitis Eclampsia Bilateral Cryptorchid (Both testicles undescended) Unilateral Cryptorchid (One testicle undescended) Low sperm count or sterility Other Reproductive Disease/disorder (please elaborate)
If yes to any of the above, please elaborate.
Tick Borne Disease

Lyme Anaplasmosis Ehrlichiosis Babesiosis Rocky Mountain Spotted Fever Other tick disease (elaborate below)
If yes to any of the above, please elaborate.
Has your dog had a prolonged recovery or side effects from general anesthsia? If so, please elaborate.
Does your dog frequently have diarrhea, constipation, vomiting, hunched back/painful abdomen? How often?
Has your dog ever been seen by a trainer, behaviorist, or veterinary behaviorist for a behavioral disorder? If so, what disorder? Please describe a typical episode. What was the outcome/resolution?
Does your dog take any medication for a behavioral disorder. If so, what medication?
Has your dog ever had an episode of exercise intolerance? (After only 5 minutes or so of running, they stumble about almost in a drunken way and recovery within a few minutes of stopping exercise.) Describe an episode and the circumstances, including weather conditions.
Has your dog ever needed surgery for an injury or illness? Please elaborate.
Do you use flea/tick preventative? If so, what product(s)?
Do you use heartworm preventative? If so, what product?
Has your dog ever had a poor reaction to a flea/tick or heartworm product? If yes, please elaborate.
Has your bitch ever whelped a litter? If yes, at what age(s)? Size of litter(s)? Any complications? If so, please elaborate.
Has your male dog sired a litter(s)? If yes, at what ages? Size of litter(s)
If female, at what age was her first heat? Approximate time between heats? Has she ever had split heats? If spayed, at what age?
If intact male, is marking in your home an issue? Inappropriate humping other dogs or objects? If neutered, at what age?
Does your dog behave aggressively toward other dogs of the same sex? (Male x male aggression or female x female aggression? Are dogs intact or neutered/spayed? If so, Please elaborate.
What type of diet do you feed your dog? Do you add any nutritional supplements? Please elaborate.
Has your dog had a health condition not addressed in this survey? If so, please elaborate.
Is this dog deceased? If so, age at death? Cause of death? (please be specific)
Do you have any questions, suggestions, or additional comments regarding this survey?
Please fill out and submit a separate health survey for each of your Windsprites.

And please submit a health survey for any deceased Windsprites.

THANK YOU VERY MUCH FOR YOUR PARTICIPATION!
If you have any questions or problems with filling out the form, contact Sidney Hoblit LHWLady@gmail.com
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