Health Information Center

On-line General Health Survey

Please complete this on-line survey for each of your Pyrs and submit it. The information supplied is kept confidential. Personal Information (second section below) will be maintained by an independent tabulator who will assign an I.D. number to each dog. Only the Dog's Health Information (third section) and the assigned I.D. number will be sent to the health committee for data collection purposes. Before submitting the form you should print it for your records.

Signature

By signing below I agree to the following:

I understand that the personal information will be held in confidence with the Independent Tabulator for record-keeping purposes only.
I understand that the GPCA Health Committee will use the data for the purpose of identifying problems in the breed.
I grant permission to the GPCA Health Committee to reprint the data in conjunction with all completed surveys received as a report of summary of the health of the breed.
I am the rightful owner or breeder of this dog, and attest that all information provided is accurate and true to the best of my knowledge.

Signature:

(For purposes of this application, printing your name in the space above constitutes a signature.)

Personal Information

Owner's Name(s):

Street Address:

City: State: Zip Code: Country:

Telephone (Day): Telephone (Evening):

Dog's Registered Name: Call Name:

Breeder's Name: Kennel Name:

Registration #: AKC ILP Foreign

Country Born:

Sire's Reg. Name: Reg. #: AKC ILP Foreign

Dam's Reg. Name: Reg. #: AKC ILP Foreign

Dog's Date of Birth: Sex: Male Female

Origin of above information:

GPCA Breeder Non-member Breeder Rescue Other (specify)

Dog's Health Information

Date of survey: Is this an update?: Yes No

Status: New Member (within last 12 months) New Titleholder (within last 12 months)

GPCA Member Regional Club (only) Non-Member (GPCA or Regional)

Is this dog intact?: Yes No (neutered/spayed) — Age neutered/spayed:

Has this dog ever been bred?: Yes No — If yes, number of litters:

Is this dog deceased?: Yes No — If yes, date of death: Cause:

Was this dog euthanized?: Yes No — If yes, reason:

Overall health of dog: Excellent Good Average Poor

Overall temperament of this dog (check all that apply):

Very shy Timid Reserved Confident Protective Aggressive toward humans

Health History — list only those health problems that were diagnosed by a licensed veterinarian or specialist:

Testing — check only those that apply:

System	Specific Name of Condition	Age at Onset
Allergies
Autoimmune
Blood/Lymphatic
Cancer
Cardiac
Dentition/Oral
Ears/Hearing
Endocrine
Eye
Gastrointestinal
Kidney
Musculoskeletal
Neurological
Reproductive
Skin
Other

BAER	Eye (OFA)	Shoulders/OCD (OFA)
Cardiac	CERF	Patella (OFA)
Hips (OFA/Penn Hip)	Elbows (OFA)	Autoimmune Thyroiditis (OFA)
Genetic Testing (specify)		CHIC Number