Health Questionnaire Please enable JavaScript in your browser to complete this form.BACKGROUND INFORMATIONDate *Owner's Name *FirstLastEmail *Dog's Name *Call Name is fineDog's Registration Number (If known)Dog's Date of BirthDog's Date of Death (if applicable)Sex of Dog *Male IntactMale - NeuteredFemale IntactFemale - SpayedHow did you obtain your Stabyhoun? *I bred the litter myselfFrom an ASA breederFrom abroadRescueOtherWhat activities does your dog participate in? *GENERAL HEALTH OF YOUR STABYHOUNHow would you rate the overall health of your Stabyhoun? *ExcellentGoodPoorVery illHas your Stabyhoun had any significant health issues? *YesNoNot sureIf yes, please give details:Is your dog on flea protection? *YesNoIf yes, what brand?Is your dog on tick protection? *YesNoIf yes, what brand? Is your dog on heartworm protection? *YesNoIf yes, what brand? Is your dog vaccinated regularly ? *YesNoIf Yes, which vaccines does your dog receive?Distemper/Parvo virusRabiesKennel CoughLeptosirosisLyme DiseaseCanine InfluenzaIf “No”, do you have titers checked instead of vaccinating?YesNoHas your dog had any adverse reaction to any vaccines?YesNoIf yes, which ones?Has your dog ever had surgery?YesNoIf yes, which procedures? Has your dog ever been anesthetized?YesNoIf “yes” any adverse reactions?Please describe and list drugs used, if known.What type of food does your dog eat?KibbleMoist CannedHome CookedRaw DietIf you feed a commercial diet, which brands?What dietary supplements do you give your dog?JointSkin/CoatTeethDigestive (probiotics)OtherIf other, please describe.What health issues do you think are most important or serious in the Stabyhoun breed and why?BREEDING HEALTH STATUSHas your dog given birth to or sired puppies? *YesNoHas your dog produced any stillborn puppies?YesNoIf Yes, please specify :GENETIC HEALTH TESTING OF YOUR STABYHOUNWhich of these tests have you had performed on your Stabyhoun (recommended at 2 years of age)?HIPS - OFAHIPS - PENNHIPHIPS -OTHERELBOWS - OFAELBOWS - OTHEREYES - CERFEYES - OTHERHEART - OFAHEART - stethoscopeHEART - DOPPLERHEART - EchocardiogramHEART - OtherSPECIFIC HEALTH ISSUES OF YOUR STABYHOUNPlease answer the question below to give us more information.PLEASE CHECK ANY THAT APPLY TO YOUR DOG.Eye problems (e.g. cataracts, glaucoma, cherry eye, entropion, chronic infections, eyelid tumor)Ear infectionsDental problems ( gingivitis/periodontal disease; underbite, overbite, missing teeth, other)Skin issues not related to allergiesAllergies (e.g., environmental allergies, flea allergy, other)Cardiovascular disorders (e.g. heart; including murmurs, PDA, heartworm disease, heart failure, others)Respiratory (breathing issues unrelated to cardiac)GI (stomach, intestine) disorders e.g. IBD, ulcers, food hypersensitivity)Urogenital- (e.g.kidney disease, chronic urinary tract infections, bladder calculi, incontinence)Liver DiseaseEndocrine diseases (e.g. Thyroid, diabetes, Cushing’s, Addison’s other)Neurologic disorders (including epilepsy, nystagmus, disc disease, muscle weakness)Immune system problems (SMRA, IMHA, ITP or other autoimmune)Bone/Joint problems (including osteoarthritis, elbow dysplasia, hip dysplasia, others)Reproductive disorders ( e.g. metritis, retained testicle, benign prostatic hypertrophy, mastitis, others)Congenital or inheritable diseases not mentioned above-e.g. kink in tail, missing toe, vWD)Cancer or tumors -spleen, liver, skin, otherDrug Reactions (confirmed or suspectedDetailed Explanation of my Stabyhoun’s health issues (see above):TEMPERAMENT OF YOUR STABYHOUNPlease check all that apply to your Stabyhoun:Aggression to other dogs (includes provoked by staring, territorial aggression, etc)Aggression toward peoplePrey aggression (intense chasing of smaller animals with “intent to kill”)Dominance toward other dogs (assertive but will not physically harm other dog unless challenged)Separation anxietyShy with new peopleFearful of objectsOTHER TEMPERAMENT CHARACTERISTICS TO SHARE?Thank you so very much for sharing your Stabyhoun’s health history with the ASA; this information is invaluable to us.Custom Captcha * = Submit
