Pembroke Welsh Corgi Degenerative Myelopathy Survey
Feel free to copy and pass on to other owners who may have
an affected Pembroke Welsh Corgi.
Please ensure, however, that only one form is filled out for any
affected dog.
1.
Have you ever owned a
Pembroke Welsh Corgi that was diagnosed with Degenerative Myelopathy? Yes ¨ No ¨
2.
Were any of your
Pembroke Welsh Corgis diagnosed with Degenerative Myelopathy during the 5-year
period from January 1995 to December 2000?
Yes ¨ No
¨
If you
answered no to question 2, you are
done unless you wish to provide contact information at the end.
If you
answered yes to question 2, please
proceed to the next section.
For each dog
you owned that was diagnosed with degenerative myelopathy during the period
from January
1995 to December 2000, please fill in the following information.
|
|
Dog 1 |
Dog 2 |
Dog 3 |
Dog 4 |
Dog 5 |
|
Sex |
male ¨ female ¨ |
male ¨ female ¨ |
male ¨ female ¨ |
male ¨ female ¨ |
male ¨ female ¨ |
|
Year born |
|
|
|
|
|
|
Year
diagnosed with DM |
|
|
|
|
|
|
If deceased,
year died. |
|
|
|
|
|
|
Did a
veterinarian diagnose degenerative myelopathy? |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
|
Were spinal
radiographs (X-rays)
taken? |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
|
Was a
myelogram (contrast X-rays of
the spine) performed? |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
|
Was an MRI
or CT (CAT) scan of the spine performed? |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
|
Was a
necropsy (autopsy or post-mortem exam) performed? |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
Yes ¨ No ¨ |
You may return this survey anonymously. However, if you are willing to submit a blood sample from affected dogs or their relatives
for DNA analysis, please fill out the following and Dr. O’Brien will contact
you. Information will be available only to researchers directly involved in the
PWCCA degenerative myelopathy study, and the identity of dogs and owners will
be kept confidential.
Name:____________________________________________________________________
_
Address:____________________________________________________________________
Phone
number:________________________ Email address:___________________________
Thank you for completing this survey! Please mail to: Degenerative Myelopathy Survey
c/o Dr. Dennis O’Brien
University of Missouri
379 E. Campus Dr.,
Columbia MO 65211