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Samoyed Identification
Code*:
*Required
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It is critical to enter this "identification
code" at the beginning of the data entry as this code
number
links together all of the databases of information for this dog
(including adverse
events, and death reports), that may be accessed at a later date.
Please use the "identification
code" from the main database entry for this Samoyed. |
| Nutrition |
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Nutrition:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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List Food Brand (s):
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List how long on that diet?:.
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Please enter any
previous diet (how long?):
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If you have changed diets, please enter previous diet. |
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Adverse reaction to diet:
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Enter any adverse reactions that your dog has had to foods. |
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Supplements :
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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Other supplements, if not listed:
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| Medication/Vaccination History |
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Heartworm medication:
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List usage:
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How often, i.e., daily, monthly, during mosquito season only
or other? |
| Please enter below all
of the diseases this dog has been vaccinated against. If you are
not sure, please ask your veterinarian for the vaccination
records. |
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Vaccinations:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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Other, if not listed above:
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Vaccination Schedule:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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Vaccination Reactions:
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If your dog has had a vaccine reaction, after completing
this form, please also fill out the
Samoyed Health Adverse Event
Incident Reporting Form. |
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Allergic Reactions:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting.
NSAID examples: Rimadyl¨ (Carprofen), EtoGesic¨
(Etodolac, Deramaxx¨ (Deracoxib), Metacam¨ (Meloxicam), Piroxicam¨
(Feldene)
Sulfa examples: Trade
name(generic), Sulfadiazine (Suladyne/Debenal),
Sulfamethazine(Sulmet/Sulfamezathine), Sulfamethoxazole (Gantanol/
Methoxal), Sulfisoxazole (Gantrisin/Soxisol/Sulfasox), Sulfadimethoxine
(Sudine/Bactrovet/Albon/Madribon), Succinylsulfathiazole
(Sulfasuxidine), Phthalylsulfathiazole(Sulfathalidine), Sulfasalazine
(Azulfidine), Mafenide (Sulfamylon cream for burns), Trimethoprim and
sulfamethoxazole (Septra/Bactrim), Trimethoprim and sulfadiazine
(Tribrissen/Di-Trim), Ormetoprim and sulfadimethoxine (Primor),
Baquiloprim and sulfadimethoxine (Zaquilan)
If your dog has had a allergic reaction to a
product, after completing this form, please also fill out the Samoyed Health
Adverse Event Incident Reporting Form. |
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Allergic signs/symptoms:
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If other, please list:
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Current Medications, if any for allergies:
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| Environmental Factors |
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Lawn/Garden Chemical Exposure History:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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Other, if not listed above:
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Note: Phenoxy
Acid Herbicides are used in the control of plants, particularly
broadleaf plants, and act to kill the plant by excess stimulation of
plant growth hormones. The best-known compounds in this class of
herbicides include 2,4-dichlorophenoxyacetic acid, (2,4-D),
2,4-dichlorophenoxypropionic acid (dichlorprop),
2,4-dichlorophenoxybutanoic acid, (2,4-DB), and
2,4,5-trichlorophenoxyacetic acid (2,4,5-T, dicamba, picloram and
dalapon). Common names for weed killers containing 2,4-D include
Weedone, Weed-B-Gon, Green Cross Weed No More 80, Lawn-Keep, Salvo, Red
Devil Dry Weed Killer, De-Pester Ded-Weed, Plantgard, Dormon, Dormone,
Brush Killer 64, Weed-Rhap, Bladex-B, Butoxy-D, Dicofur, Ipaner, Moxon,
Netagrone, Pielik, U 46 DP, Verton 38, B-Selektonon, Silvaprop,
Agricorn D, Acme LV 4, Acme LV 6, Coprider, D50, DMA 4, Emulsamine,
Fernesta, Ferxone, Macondray, Pennamine, Tributon, Weedatul, Agroxone,
Spritz-Hormin, Desormone, Decamine, Weedar, R-H Weed Rhap 20, and
Scott's 4-XD Weed Control. |
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List chemical products used:
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Environment:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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Living:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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Flea/tick control:
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Select all that apply. Windows users: Hold down Ctrl
key while selecting.
Mac Users: Hold down the Command key while selecting. |
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Flea/tick brands-list products and how
often they are used:
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