NIH Survey - SCWTCA Endowment, Inc.

Your Name:

First

Last

Your Email:

Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

International Address

If the address line is not working for you and you are an international owner please update it here.

Your Wheaten's Full Name:

For example: Innisfree's Annie Sullivan

Your Wheaten's Call Name:

Where did this Wheaten live?

Inside
Outside
Kennel

Was this dog a(n):

An only Dog
Lived with other dogs
Lived with other pets

Lifespan:

Your Wheaten's Date of Birth

Is this dog still alive

Yes
No

Date of Death:

Was this dog euthanized?

Yes
No

Cause of death?

If the dog was euthanized due to old age state that. If it was euthanized due to an illness or accident be specific. If the dog was euthanized due to progression of a disease state that.

What was the age that this dog died?

How did this dog age?

who medication?

In regards to aging please make additional comments here:

Vaccinations & Anesthesia

Did this dog receive any of the following vaccinations:

Other Vaccinations:

Frequency of vaccinations:

When did you stop vaccinating?

Was there any reaction to a vaccination?

Did you do titers?

Food & Supplements

Type of diet(s) this dog had: (check all that apply)

Supplements you gave this dog:

Other Supplements:

Medical Information

Did this dog show any of the following signs of illness:

Which signs of illness were chronic?

Other Conditions:

Please let us know of any other conditions/issues that this dog had.

Was your dog diagnosed with:

Type of cancer:

Please explain the type of cancer, the area it was found and any treatments you used.

Was your dog's spleen removed? Please tell us about that.

Type of tumor and where?

Please explain

Type of dermatitis:

What medications were prescribed for this dog?

Did your dog ever have a surgery?

Yes
No

Reason for surgery?

If this dog had anesthesia was their a reaction? If so please explain.

Type of Allergies:

Describe what the dogs allergies were and the treatments you used.

Other Supplements?

Eye Conditions & Clearances:

Reported to OFA & SCWT Database
None
Yes there were eye conditions

Eye Conditions:

Did your dog ever have an infectious disease?

Yes
No

Type of Infectious Disease:

Did this dog have Hip Clearances?

Yes
No

Did this dog develop hip dysplasia? Please explain.

Did this dog have eye clearances?

Yes
No

Did this dog develop eye disease or eye issues? Please explain.

Annual Testing and Genetic Testing

Did your dog have blood and urine testing?

Yes - annually
Yes - more often than annually
Yes - periodically
Not at all

Thinking back to the annual health testing were any tests abnormal? If so which values?

You can just attach any health testing below.

Check all that apply: Did this dog have any of the genetic test results?

Did your dog received any of the following treatments for parasites? (check all that apply)

Was there any adverse reaction to flea or tick medication? If so please explain.

Reproduction:

Was this dog:

Female used in breeding program - never spayed
Male used in breeding program - never neutered
Female not used in breeding program - spayed
Male not used in breeding program - neutered
Female used in breeding program - eventually spayed
Male used in breeding program - eventually neutered
Female never bred never spayed
Male never bred never neutered

Types of deliveries your bitch had:

C-section planned
C-section emergency
Natural

Did this bitch have any of the following:

Did this stud dog have any of the following:

Other reproductive issues:

Lifestyle & Personality

Did this dog exhibit any of the following traits of an all purpose farm dog?

Please explain other traits.

Did your dog exhibit any of the following prey drive skills:

What participation/activities did your dog have?

Other Activities:

What forms of exercise did your dog get?

Was this Wheaten a jumper?

Yes jumped straight up
Yes this Wheaten did the Wheaten whirl (360's)
No this Wheaten did not jump
Tried to train the dog not to jump of whirl - succesfull
Tried to train the dog not to jump or whirl - unsuccesful

Describe play time and exercise:

Include the types of toys this dog liked to play with. Such as squeaky toys, ropes, balls, attacking the sprinklers, bunny runs, bow play position, chasing squirrels etc etc

Thinking back on your dogs personality what would you describe it as?

What made your Wheaten Terrier uniquely "Wheaten"?

Is there anything else you think we need to know about your dog?

Permissions and Signatures

If you wish to have these records updated in the SCWT Health & Pedigree Database please check this box: Dogs who are entered in the database receive a shamrock on their database page for participation and they receive a heart for a lifespan completion Owners receive a ticket to win an iPad drawing in October.

Yes
No

Name, city, state and phone number of your dogs veterinarian

Will you authorize NIH to call your veterinarian to obtain medical records? The value of this study depends on accurate health information, many of which you might have forgotten. Veterinary records help confirm diagnoses, treatments, and causes of death, ensuring that the data collected is as reliable as possible. Many health conditions can be difficult for us to classify based on memory alone. Access to veterinary records allows researchers to better undersand disease patterns, longevity and aging in SCWT's. This information may help guide future health research and improve the breed's well-being for generations to come. If you are willing, please upload relevant veterinary records or authorize us to contact your veterinarian directly. Any records provided will be kept confidential should you wish and the information used soley for research purposes. Every records matters and your dog matters. Even if your dog lived a long, healthy life, those records are just as important as records from dogs with significant health issues.

Yes, I agree for you to have my dogs medical records. I have attached them or will email them to you.
No, I will obtain them for you
No, I do not wish to submit vet records

Upload Medical records here or email them to Dr Parker directly.

Drag & Drop Files, Choose Files to Upload

Signature - I grant permission to the Ostrander laboratory at the National Institutes of Health to contact my veterinarian for specific health records, as indicated within this survey, regarding my dog listed above as they pertain to the SCWT life-time health study.

Clear Signature

Date

Wheaten Photo