Health Questionnaire

Help the Welsh Terrier Club of America’s Health Committee gather important information about the breed. The information you provide will assist the WTCA in the search and selection process for researchers studying conditions that affect the breed.

This form provides Welsh Terrier owners a means to document health related incidents and causes of death.

This form is received in an anonymous format, there is a place at the bottom to provide contact details if you wish.
 

Date of Health Incident or Death (YYYY-MM-DD):

Is this a Health Incident or a Death?
Health Incident
Death
Unexpected Test Result

 

CONDITION/CIRCUMSTANCES:

Describe the occurrence, time of day, signs, symptoms, duration, medications, veterinary recommendations and outcome. (Continue in “Additional Information” at the bottom if more space is needed):

 

THE INFORMATION BELOW IS VERY IMPORTANT FOR US TO BETTER UNDERSTAND YOUR WELSH TERRIER AND THE HEALTH INCIDENT.

Please fill out what you can, it will help us to analyze all of the reports that get submitted over time – the incidents, deaths and trends.  We have tried to make it easy with selection options and check boxes.

Are you the breeder of this Welsh Terrier?
Yes
No

If not, have you notified your breeder?
Yes
No

Is the breeder a Welsh Terrier Club of America (WTCA) member?
Yes
No
Do not know

Age of your Welsh Terrier (when reported incident occurred):

Welsh Terrier Gender:
Male
Female

Is this Welsh Terrier:
Spayed or
Neutered – at what age:
Intact

Has your Welsh Terrier ever been bred?
Yes
No

What have you fed your Welsh Terrier? Check all that apply.
Dog Food (kibble) – non-prescription

Dog Food (canned) – non-prescription

Prescription dog food

Homemade diet or commercial raw diet

If commercial diet, what is the percentage
of protein listed on the food?

 

IMMUNIZATIONS (Vaccinations):
What immunizations has your Welsh Terrier had? Check all that apply.
DHPP* – Year of last
booster (YYYY):
*Commonly called the canine distemper vaccine. This is the most common combination vaccine given to dogs. The initials DHPP refer to the diseases included in the vaccine. Distemper, Hepatitis, Parvo and Parainfluenza

DHLPP** – Year of last
booster (YYYY):
**This is the same as the above but it also includes vaccine for
Leptospirosis, aka ‘Lepto’.

Rabies – Year of last
booster (YYYY):
Lyme – Year of last
booster (YYYY):
Bordatella
(Kennel Cough )- Year of last booster (YYYY):
Others (names and years): 

 

IMMUNIZATIONS (Vaccinations):

How often did you give your dog vaccinations?
Annual
Vaccinations
Every 3
Years (or other)
None after puppy vaccines
I had titres done on my dog (check if applies even if you do vaccinations also)

Do you use a flea / tick preventative?
 Yes: Which brand?
No

Do you use a heartworm preventative?
Yes: Which brand?
No

 

Where does/did your Welsh Terrier live at the time of the incident? Please include the State or Province, along with the Country:

Please provide any additional information that you think will be useful for the WTCA to better understand this health incident of your Welsh Terrier:

How did you learn of this form?

Optional: If you are willing to be contacted privately to provide further information, please provide:
Phone (include area code)
and/or Email address