Broad Institute Golden Retriever Cancer Studies
Broad Institute Health Status Update
Thank you for submitting a blood sample from your dog to the Broad Institute of MIT and Harvard.
We would be grateful if you could take a moment to fill out this form. This will help us get the most recent update on the health status of your dog.
Please fill out this online form or download and fill in the PDF form and send by email as an attachment to dog-info@broad.mit.edu or print it out and mail it to
Dog Genome Group
7 Cambridge Center 6th Floor
Cambridge, MA 02142.
Today’s Date: __________________
Your name: _________________
Dog’s Birth Date: __________________
Dog’s call name: __________________
Coat color: _________________
Dog’s registered name: ________________
Dog’s AKC number (or other registering organization, please specify) #: ____________
Please check the disease(s) that your dog has ever had:
Addison’s disease Date of diagnosis: ____________
Atopy Date of diagnosis: ____________
Cancer Hemangiosarcoma Date of diagnosis: ____________
Osteosarcoma Date of diagnosis: ____________
Mast Cell Tumors Date of diagnosis: ____________
Melanoma Date of diagnosis: ____________
Mammary Tumors Date of diagnosis: _____________
Lymphoma ( if subtype is known: B-Cell T-Cell
Date of diagnosis:___________
Other Cancers: Date of diagnosis: ___________
Cardiovascular disease ARVC Date of diagnosis:____________
Dilated Cardiomyopathy Date of diagnosis:_________
Degenerative Myelopathy Date of diagnosis: ____________
Demodikos Date of diagnosis: ____________
Diabetes Date of diagnosis: ____________
Epilepsy Date of diagnosis: ____________
Exocrine pancreatic insufficiency Date of diagnosis: ____________
Eye disease Date of diagnosis: ____________
Hypothyroidism Date of diagnosis: ____________
Loss of claws Date of diagnosis: ____________
Obsessive Compulsive Disorder Date of diagnosis: ____________
Periodic fever Date of diagnosis: ____________
Pyometra Date of diagnosis: ____________
Renal Disease Date of diagnosis: ____________
Rheumatic disease Date of diagnosis: ____________
Other, please specify: __________________ Date of diagnosis: ____________
Is your dog deceased?
Yes No
Date of death: ___________ Cause of death: ____________________
Please provide your veterinarian’s contact information so that we may obtain further information about the diagnosis:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
I give the Broad Institute of MIT and Harvard permission to contact my veterinarian.
Additional notes you would like to include:
________________________________________________________________________________________________________________________________________________
Thank you very much for your help!!!!
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