Staffordshire Bull Terrier Club of the USA

Health Information Committee

Dear Stafford owner:

The SBTC/USA's Health Information Committee is conducting an ongoing survey into the health of the Staffordshire Bull Terrier breed of dog. Our aim is to identify health "problems" in the breed and then to work to make the lives of every Stafford longer and healthier.

The Committee would like for you to complete this health survey form. Any amount of information that you can provide would be appreciated.

You will notice that we have listed a lot of different conditions that MAY occur. If your dog has had any of them, select the box and select "Yes" instead of the default "No". Then fill in the age of the dog when the condition developed. If the dog did NOT have a condition, skip to the next question.

If your dog has had none of the problems listed, we would still like to have the survey completed. Good health is good news!

If your dog is no longer living, please fill out as much of the survey as you can. The general health of the dog and the age and cause of death are important pieces of information.

Your help in filling out this survey will be an important part of assuring Stafford owners of the future that their dogs will have long and healthy lives.

On behalf of the breed and the Staffordshire Bull Terrier Club of the USA, we thank you for your participation in this project.

If you would like more information about the SBTC/USA Health Committee or if you have health concerns about your Stafford that you would like to discuss, send an email to sstone@pvtnetworks.net .



SURVEY DIRECTIONS

All fields on the survey form that have an asterisk (*) in front are a required entry.

The "Yes/No" selection fields are all defaulted to "No".

For your convenience, there is a reset button for the form.



THE SURVEY



Owner Information

* Is this an update to an earlier form?:

* Owner's Name:
* Address1: Address2:
* City: * State: * Zip or Postal Code:
* Country: * Email:
Daytime Phone: Evening Phone:



Breeder Information

* Breeder' Name:
* Kennel Name:



Registration Information

* Dog's Registered Name:
* Call Name:
* AKC Registration #:
Sex: Date of Birth:

Sire's Reg. Name: AKC Reg. No.:
Dam's Reg. Name: AKC Reg. No.:

This Dog's General Health:



Is this dog deceased?: Age at death:

Cause of death:

Was an autopsy performed to determine cause of death?:

If euthanized, reason for doing so:



Has this dog ever been bred?: Number of litters:
Spayed/Neutered?: Age done:



Hips

Has this dog been x-rayed for hip dysplasia?: Age done:
GDC No.: OFA No.: Hip Dysplasia: Age:

PennHIP Palpation Score (L): (R): X-Ray Results:



Skeletal

Osteochondritis Dessicans (OCD): Age:
Panosteitis: Age:
Patellar Luxation: Age:
Arthritis: Age:
Spinal Myelopathy: Age:
Cervical Vertebral Instability (Wobbles): Age:
Other spinal problems: Age: Description:
Dwarfism: Age:



Eyes & Ears

Eyes:
Have this dog's eyes been examined by a specialist?: Age:
Entropion: Age:
Ectropion: Age:
Cataracts: Age:
Persistent Pupilary Membrane: Age:
Other eye problems: Age: Description:

Ears:
Deaf: Age:
Hearing impaired: Age:
Other ear problems: Age: Description:



Skin

Chronic hot spots: Age:
Chronic ear infections: Age:
Seborrhea: Age:
Demodectic mange: Age:
Persistent staph infection (Pyoderma): Age:

Allergies: Age: Specify type:

Other skin problems: Age: Description:



Cancer
Bone: Age: Location:
Breast: Age:
Muscle: Age: Location:
Lymphatic: Age:
Leukemia: Age:
Head (mouth, etc.): Age: Location:

Other cancer: Age: Description:



Blood Problems

Anemia: Age:
Hemophilia: Age:
Von Willebrand's Disease: Age:
Autoimmune Hemolytic Anemia: Age:
Other blood problems: Age: Description:

Hormone Deficiencies:
Diabetes: Age:
Pancreatitis: Age:
Addison's Disease: Age:
Pituitary: Age:
Thyroid: Age:



Kidney Problems

Cystitis (Bladder Infection): Age:
Congenital Kidney Disease: Age:
Chronic Interstitial Nephritis: Age:
Stones: Age:
Other kidney problems: Age: Description:



Heart Problems

Valves: Age:
Stenosis: Age: Stenosis type:
Murmurs: Age:
Congestive heart failure: Age:
Cardiomyopathy: Age:
Patent Ductus Arteriosis: Age:
Septal defect: Age:
Other heart problems: Age: Description:



Reproductive Problems

Females:
Irregular heats: Age: Months between heats:
Refusal to accept male: Age:
Failure to conceive: Age:
Fetal death (before birth): Age:
Fading puppies: Age:
Vaginal infection: Age:
Pyometra: Age:
Mastitis (bad milk): Age:
Difficulty whelping: Age: Description:
Caesarean sections: Age: How often:

Males:
Lack of interest in female: Age:
Impotence (inability to breed willing female): Age:
Sterility (no sperm): Age:
Abnormal sperm: Age:
Abnormality of testicles: Age:
Genital infection: Age:
Prostatitis: Age:

Both:
Other reproductive problems: Age:

Description:

Bloat: has this dog ever bloated?: Age: How often:
Did this dog die of bloat?:
Seizures: has this dog ever had seizures (Epilepsy)?:
Age of first seizure:



Immune System

Has this dog ever been diagnosed with a condition in which immune system failure was suspected?:

What was the condition:

How was the diagnosis made:



Temperament

How would you describe your dog's temperament? (Check all that apply):

Very Shy Timid Reserved

Confident Protective Aggressive



Please include any additional comments about this dog's health:





If you have a question, comment or problem concerning this form contact Terry Stewart at stoutheart_staffords@yahoo.com




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Webmaster Terry G. Stewart