Juvenile Renal Dysplasia Study

PLEASE NOTE: *ALL INFORMATION IS CONFIDENTIAL*

Form For Participants in Liver Shunt DNA Research

General Information

Owners Name:

Breed (Choose):

or Breed(enter manually):

Animals AKC or other registration #:

Animals Name

Date of Birth: (mm/dd/yyyy) Click on calendar to choose

Sex:

Please Select Category for this animal:

A. THIS ANIMAL HAS LIVER SHUNT

B. THIS ANIMAL DOES NOT HAVE BUT HAS PRODUCED OFFSPRING LIVER SHUNT

C. THIS ANIMAL DOES NOT HAVE LIVER SHUNT BUT HAS SIBLINGS THAT HAVE BEEN DIAGNOSED WITH LIVER SHUNT.

D. THIS ANIMAL HAS NEVER PRODUCED OFFSPRING WITH LIVER SHUNT

For Animals That Have Been Diagnosed with Liver Shunt

At what age were symptoms of Liver Shunt first noticed?

At what age was Liver shunt diagnosed, and what tests have been done on this animal to determine Liver shunt status?

Does this animal have siblings that have Liver shunt?

How many siblings had Liver Shunt?

Please describe how Liver Shunt was diagnosed for the siblings:

What was the litter size for this animal?

Is there any relevant information including Liver Shunt status and testing of the parents of this animal?

For Animals That Produced Offspring with Liver Shunt

This sire/dam has produced how many offspring in total?

How many Liver Shunt offspring were produced?

Please describe how Liver Shunt was diagnosed for the offspring:

For Animals That Do Not Have Liver Shunt, but Have Siblings That Do.

What tests were done to determine Liver shunt status of the siblings?:

How many puppies were in the litter?:

Is there any relevant information including Liver Shunt status and testing of the parents of this animal?

For Animals That Never Produced Offspring with Liver Shunt

This sire/dam has produced how many offspring?

How many partners has this animal been bred to?:

General Medical History

Please list any medical conditions(including genetic disoLiver shunters) past or present that this animal has been diagnosed with:

Overall Health: This animal does not have any known health problems at this time, and has not been diagnosed with any genetic disoLiver shunters.

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Form For Participants in Liver Shunt DNA Research
General Information
Owners Name:
Breed (Choose):
or Breed(enter manually):
Animals AKC or other registration #:
Animals Name
Date of Birth:	(mm/dd/yyyy) Click on calendar to choose
Sex:
Please Select Category for this animal:
	A. THIS ANIMAL HAS LIVER SHUNT
	B. THIS ANIMAL DOES NOT HAVE BUT HAS PRODUCED OFFSPRING LIVER SHUNT
	C. THIS ANIMAL DOES NOT HAVE LIVER SHUNT BUT HAS SIBLINGS THAT HAVE BEEN DIAGNOSED WITH LIVER SHUNT.
	D. THIS ANIMAL HAS NEVER PRODUCED OFFSPRING WITH LIVER SHUNT
For Animals That Have Been Diagnosed with Liver Shunt
At what age were symptoms of Liver Shunt first noticed?
At what age was Liver shunt diagnosed, and what tests have been done on this animal to determine Liver shunt status?
Does this animal have siblings that have Liver shunt?
How many siblings had Liver Shunt?
Please describe how Liver Shunt was diagnosed for the siblings:
What was the litter size for this animal?
Is there any relevant information including Liver Shunt status and testing of the parents of this animal?
For Animals That Produced Offspring with Liver Shunt
This sire/dam has produced how many offspring in total?
How many Liver Shunt offspring were produced?
Please describe how Liver Shunt was diagnosed for the offspring:
For Animals That Do Not Have Liver Shunt, but Have Siblings That Do.
What tests were done to determine Liver shunt status of the siblings?:
How many puppies were in the litter?:
Is there any relevant information including Liver Shunt status and testing of the parents of this animal?
For Animals That Never Produced Offspring with Liver Shunt
This sire/dam has produced how many offspring?
How many partners has this animal been bred to?:
General Medical History
Please list any medical conditions(including genetic disoLiver shunters) past or present that this animal has been diagnosed with:
Overall Health:	This animal does not have any known health problems at this time, and has not been diagnosed with any genetic disoLiver shunters.