The Irish Wolfhound
Lifetime Cardiac Health Study |
|
Date___________________________ Owner Name_________________________________________________________________ Street ______________________________________________________________________ City____________________________________ State______________ Zip_________________ Dog's Call Name______________________ Dog # in database (will be assigned)_______________ Dog's birth date__________________ Sex____________ Body Weight __________________ Registered Name of Dog (optional) _____________________________________________________ Is this dog spayed or neutered: ___Y ___N If yes, at what age: _____________________ Does this dog have any health problems at this time: ___Y ___N If yes, please explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Has this dog had any health problems in the past: ___Y ___N If yes, please explain: ______________________________________________________________________________________________ ______________________________________________________________________________________________ Has this dog had a change in exercise intolerance: ___Y ___N Can this dog walk 1/2 mile: ___Y ___N Does this dog have a chronic cough: ___Y ___N Excessive panting with minimal exercise: ___Y ___N Swelling: ___Y ___N Recent weight loss: ___Y ___N Recent behavior changes ___Y ___N Fainting spells: ___Y ___N Episodes of weakness: ___Y ___N Changes in appetite: ___Y ___N Has a chest x-ray ever been done: ___Y ___N Was it normal: ___Y ___N Has an EKG ever been done: ___Y ___N If yes, at what age: _____________ Was this EKG normal: ___Y ___N
Has an echocardiogram ever been done: ___Y ___N Was it normal: ___Y ___N Please give reason for past EKG, chest x-ray or echo if done: _______________________________________ _________________________________________________________________________________
STUDY ENTRY: EKG NORMAL ____Y ____N (will be recorded by vet or taken from report)
Has a relative of this dog died of heart disease or been diagnosed with heart disease ____Y ___N Does this dog take any regular medications: ___Y ___N If yes, please list (include vitamins & herbs, etc): 1.______________________________________ dose:____________ Start date:______________ 2.______________________________________ dose:____________ Start date:_______________ 3.______________________________________ dose:____________ Start date:______________ 4.______________________________________ dose:____________ Start date:_______________ 5.______________________________________ dose:____________ Start date:______________ 6.______________________________________ dose:____________ Start date:_______________ 7.______________________________________ dose:____________ Start date:______________ 8.______________________________________ dose:____________ Start date:_______________
Please attach a copy of a recent EKG (within the last two months) if this entry is not at an EKG testing event. If the EKG is not available, a copy of the formal report can be attached. Please include a strip of the EKG if at all possible. Thank you very much. |