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!!!!

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download