This survey is intended for Cesky Fouseks imported for CFNA and dogs bred through the CFNA breeding program. Obtaining data on every dog in our program is vital, not just on those selected for breeding. Health conditions included in the survey have been shown to have a genetic link or that are suspected of including genetic factors. Data that you supply will be added to the CFNA health data base for use by the CFNA Breeding Committee. Data will only be publicly reported in summary form in CFNA publications.. Please use this form to provide health data on your dog (living or deceased). If you have more than one dog, please complete a separate survey for each dog.
Contact Information Owner Name(Required) Note: In some cases there are multiple owners, e.g. Bill & Mary Jones. Please enter only one name for the best individual to contact for follow-up information
First
Last
Address
Dog Details
Breed details What breed is the dog? (Most dogs will be “”Domestic CFNA bred dog”. (If “Other”, please specify.
Is dog living or deceased? Age at death Enter a number to nearest 1/2 year. Eg. 9.0 or 10.5
Cause of death Details on cause of death
Sex Neutered or Spayed? Age sterilized Enter number in years
Health Issue Screening Questions please review the following general health disorder categories. Clicking “Yes” for any general category will display a list of more detailed items later in the survey. Items about specific disorders and space to describe those conditions will appear below for only those categories where you have identified a problem. When in doubt, click “Yes”. You can go back and change your answer to “No” if a specified conditions does not apply.
Eye Has your dog experienced any eye or vision problems?
Ear Has dog experienced any ear or hearing problems?
Dental Has dog experienced any dental or teeth problems?
Skin Has dog experienced any skin or coat problems? (Include food & environmental allergies)
Gastrointestinal Has dog experienced any gastrointestinal disorders such as sensitive stomach, frequent vomiting or diarrhea ?
Respiratory Has dog experienced any respiratory disorders?
Orthopedic Has dog experienced any orthopedic (e.g. bone & joint) disorders?
Cardio Has dog experienced any cardiovascular disorders?
Urinary Has dog experienced any urinary system disorders?
Blood Has dog experienced any blood or lymphatic system disorders?
Endocrine Has dog experienced any endocrine system disorders such as thyroid or diabetes problems?
Reproductive Has dog experienced any reproductive disorders?
Neurological Has dog experienced any neurological disorders?
cancer Has dog experienced any cancer or tumor disorders?
Behavior Does dog display gun shyness, fear of loud noises, timidity, fearfulness of strangers, separation anxiety, destructiveness, aggressiveness, growling or snapping at children etc.?
Eye and Vision Disorders Please tell us more about eye and vision disorders. Review the listed conditions below and indicate which one(s) your dog has experienced. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Distichiasis
A distichia is an eyelash that arises from an abnormal location on the eyelid or grows in an abnormal direction.
Entropion Entropion is a genetic condition in which a portion of the eyelid is inverted or folded inward. This can cause an eyelash or hair to irritate and scratch the surface of the eye,
Ectropion Ectropion: the margin of the eyelid rolling outward, resulting in exposure of the palpebral conjunctiva (the portion of tissue that lines the inner lids).
Cataracts Retinal Dysplasia Retinal dysplasia can be focal, multifocal, geographic, or accompanied by retinal detachment. Focal and multifocal retinal dysplasia appears as streaks and dots in the central retina.
Progressive Retinal Atrophy In progressive retinal atrophy (PRA), deterioration of the retinal cells causes blindness.
V Notes Notes about eye problems. (age of onset, symptoms, treatment, outcome, etc.)
Ear and Hearing Disorders Review the listed conditions below and indicate which one(s) your dog has experienced. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Chronic ear infection- Only note if this has been a frequent and recurring problem.
Deafness Ear Notes
Notes about ear problems. (age of onset, symptoms, treatment, outcome, etc.)
Dental Review the listed conditions below and indicate which one(s) your dog has experienced. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Butt-bite Cross-bite Over-bite Under-bite Extra teeth Missing teeth Dental Notes
Notes about dental problems. (age of onset, symptoms, treatment, outcome, etc.)
Skin and Coat (Includes food/medicine allergies) Review the listed conditions below and mark “Yes” or “No” If disorder is not listed, select “Other” to specify the condition. Space is also provided for a brief explanation/description of the health issue .
Atopic Dermatitis Atopic dermatitis is a disease in which there is an inherited tendency to develop antibodies in response to exposure to allergens that are inhaled or absorbed through the skin.
Food/Allergy Food or med allergy. Proteins in beef, dairy products, wheat, chicken, egg, and soy products are often linked to food allergies in dogs.
Alopecia Alopecia is defined as a loss of hair, partial or complete, in areas where it normally grows. Hair loss is the clinical sign of alopecia. The hair loss can be very noticeable or very inconspicuous. It can be a single small patch, multiple small patches, symmetric (the same on both sides), or cover the entire body.
Autoimmune Skin Disease In autoimmune skin disease, the immune system attacks itself by mistake, causing illness. The immune cells fail to distinguish the body’s normal healthy cells from foreign cells and thus try to destroy the normal tissues.
Skin Notes Notes about skin/coat problems. (age of onset, symptoms, treatment, outcome, etc.)
Gastrointestinal disorders Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue
Bloat Gastric dilation and volvulus syndrome (GDV), more commonly referred to as Stomach torsion or bloat, is a disease in dogs in which the animal’s stomach dilates and then rotates, or twists, around its short axis.
Megaesophagus
Occurs in puppies. It is caused by a developmental disorder involving the nerve plexus in the lower esophagus. Peristaltic activity stops at the level where the esophagus is paralyzed, and food can go no further. In time, the esophagus above the inert segment enlarges and balloons out.
Vomiting Chronic Vomiting Symptoms include heaving, retching, and partially digested food coming up, along with a yellow fluid called bile. Chronic condition.
Colitis Chronic Colitis: inflammation of the large intestine, cases recurrent or persistent diarrhea in the dog. Inflammation of the colon lining prevents residual water from being absorbed efficiently.
Gastro Notes Notes about gastrointestinal problems. (age of onset, symptoms, treatment, outcome, etc.)
Respiratory Review the conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue .
Laryngeal Paralysis Hereditary paralysis of the voice box or larynx in dogs is part of a generalized disorder involving several nerves (polyneuropathy syndrome).
Respiratory Notes Notes about respiratory problems. (age of onset, symptoms, treatment, outcome, etc.)
Orthopedic Conditions Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
OCD
Osteochondritis Dissecans is a condition in which normal change of cartilage to bone, is disturbed. Lameness is most common symptom ,Onset of lameness may be sudden or gradual, and may involve one or more limbs. Lameness becomes worse after exercise.
Hip Dysplasia Hip dysplasia is the failure of the hip joints to develop normally (known as malformation), gradually deteriorating and leading to loss of function of the hip joints.
Elbow Dysplasia A condition characterized by a series of four developmental abnormalities that lead to malformation and degeneration of the elbow joint.
CCL or ACL Cruciate ligament rupture (CCL) or anterior cruciate ligament, (ACL) is the tearing of an important ligament in the stifle joint (knee), resulting in partial or complete joint instability, pain, and lameness.
HOD Hypertrophic Osteodystrophy (HOD) is a bone disease that occurs in fast-growing large and giant breed dogs. typically first presents between the ages of 2 and 7 months. HOD is characterized by decreased blood flow to the metaphysis (the part of the bone adjacent to the joint) leading to a failure of ossification (bone formation) and necrosis and inflammation of cancellous bone.
Ortho Notes Notes about orthopedic problems. (age of onset, symptoms, treatment, outcome, etc.)
Cardiovascular Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Subaortic stenosis a narrowing (stenosis) of the area underneath, the aortic valve, that causes some degree of obstruction or blockage of the blood flow through the heart. First signs of it may be present at birth or appear in the first year of life.
Pulmonic stenosis A congenital heart defect of the semilunar valve that is between the right ventricle and the pulmonary artery (great vessel that takes blood to the lungs). The leaflets of this valve are thickened and/or partially fused together. Dogs with advanced disease may have exercise intolerance, collapsing, arrhythmias, or heart failure.
Tricuspid Valve Defect When the AV valve in the right side of the heart -the tricuspid valve- is malformed at birth (called dysplasia of the valve), blood flow through the heart is less efficient: with each heartbeat, a portion of the blood that is meant to travel in the normal direction instead spills backward to where it just came from.
Cardio Notes Notes about cardiovascular problems. (age of onset, symptoms, treatment, outcome, etc.)
Urinary system Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Urolithiasis (stones) crystals in the urine combine to form stones, also called calculi or uroliths. These can be found anywhere in the urinary tract,
Urinary Notes Notes about Urinary problems. (age of onset, symptoms, treatment, outcome, etc.)
Blood blood and lymph system disorders. Review the listed conditions ; mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue
Hemophilia Hemophilia is a bleeding disorder of varying severity that is due to a deficiency in specific clotting factors.
Von Willebrand's disease An inherited bleeding disorder caused by a lack of von Willebrand factor (vWF), which plays an essential role in the blood clotting process.
Blood Notes Notes about blood or lymphatic system problems. (age of onset, symptoms, treatment, outcome, etc.)
Endocrine System Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation of the health issue.
Addison's Disease Addison’s Disease (hypoadrenocorticism). It is a disease that results from the reduction in corticosteroid secretion from the adrenal gland.
Cushing’s disease Cushing’s disease refers specifically to an increase in cortisone due to a benign tumor of the pituitary gland.
Diabetes mellitus Diabetes mellitus is generally referred to as diabetes Some cases may be the result of autoimmune disorders and/or damage to the pancreas by puppyhood diseases such as infectious canine parvovirus. Genetics also plays a role, and juvenile onset diabetes is thought to be an inherited trait in some breeds.
Thyroid disorder Please describe specific type of thyroid disorder below
Endocrine Notes Notes about endocrine problems. (spcific type, age of onset, symptoms, treatment, outcome, etc.)
Reproduction Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Cryptorchid-Monorchid Cryptorchidism means that one or both of a dog’s testicles have not descended into the scrotum. If this does not happen by 8 weeks, the dog is generally diagnosed as cryptorchid.
Phimosis Phimosis is the inability to expose the penis and may be due to an abnormally small preputial opening. It may be hereditary or acquired as a result of trauma, inflammation, or bacterial infection.
Testicular Atrophy Testicular degeneration is common in dogs over 5 years of age. The testes may be smaller than normal. The semen will have increased primary abnormalities and decreased concentration
Abnormal Sperm Azoospermia is when the ejaculatory fluid contains no sperm · Oligozoospermia means the number of spermatozoa is low · Aspermia is the lack of ejaculation .
Irregular heat cycle Follicular cysts are fluid-filled structures develop within the ovary and lead to prolonged secretion of estrogen and continuous signs of estrus (heat) and attractiveness to males.
Infertility A female dog’s inability to get pregnant may be because the dog isn’t producing eggs or the proper hormones to sustain pregnancy and stimulate birth.
Pregnancy issues Females used in breeding may miscarry, have complications with delivery etc. Give details below
Reproduction Notes Notes about reproduction system problems. (specific type, age of onset, symptoms, treatment, outcome, etc.)
Neurological disorders Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Epilepsy Seizures are the result of a disturbance in the electrical activity of brain cells. Inherited idiopathic epilepsy is genetically transmitted in some breeds of dogs. Seizures typically begin between 1 and 3 years of age.
Caudea Equina Syndrome A condition in which the nerves of the hind limbs and rear end are compressed. Associated with a number of pathologic changes in the spine that resulting compression of nerves The typical age is about 6 to 7 years, with males more commonly affected.
Degenerative Myelopathy Affects dogs 5 years of age or older. A slowly progressive loss of coordination in the hind limbs, with increasing weakness. Deterioration of structures in the spinal cord that are responsible for conduction of nerve impulses (specifically the loss of myelin and degeneration of axons in the white matter).
Neurological Notes Notes about neurological system problems. (specific type, age of onset, symptoms, treatment, outcome, etc.)
Cancer or Tumors Review the listed conditions below and mark “Yes” or “No” for each one. If your dog’s disorder is not listed, you may select “Other” and specify the condition. Space is also provided for a brief explanation/description of the health issue.
Mast cell tumor Mast cell tumor
Mast cell tumors (MCT) in dogs are very common, skin tumors in dogs. Can arise from any skin site on the body, and can have a variety of appearances.
Lymphoma Type of cancer that originates in the lymphocyte cells of the immune system. There are two forms of lymphocytes: B and T cells.
Hemangiosarcoma (HSA) is an aggressive, malignant cancer of the blood vessels that often grows as a mass in the spleen, liver, or heart, but can also be found in other parts in the body.
Testicular cancer Testicular tumors are one of the most common tumors in older intact male dogs. The three most common types are Sertoli cell tumors, interstitial (Leydig) cell tumors and seminomas.
Mammary cancer Mammary tumors in female dogs account for 42% of all diagnosed tumors, with a lifetime risk of 23-34%
Osteosarcoma Bone cancer develops deep within the bone and becomes progressively more painful as it grows outward and the bone is destroyed from the inside out. Lameness may occur suddenly or start intermittently and progress over several weeks.
Cancer Notes Notes about cancer. (specific type, age of onset, symptoms, treatment, outcome, etc.)
Temperament Issues Behavior and temperament issues are frequently the result of complex interaction between heredity, environment, exposure/training and random events. Please identify the general temperament issues from those listed below. For those conditions selected, please describe in more detail the dog’s behavior, its severity and circumstances under which the problem occurs.
Separation Anxiety Anxious dogs may show following signs when left, or about to be left, on its own: Shaking, shivering, or trembling.; excessive salivation; restlessness, agitation, or pacing; whining, barking or howling; chewing or scratching at doors, floor, windows, curtains, etc; loss of appetite.
Fearfulness Excessive Fearfulness: when exposed to particular sounds, objects, persons or situations. Extreme fear is characterized by exaggerated cowering, and/or vigorous attempts to escape, retreat or hide from the feared object, person or situation.
Excitability Extreme excitability is characterized by a general tendency to over-react. The excitable dog barks or yelps hysterically at the slightest disturbance, rushes toward and around any source of excitement, and is difficult to calm down.
Aggression: Typical signs of moderate aggression in dogs include barking, growling and baring teeth. More serious aggression generally includes snapping, lunging, biting, or attempting to bite.
Cooperation A lack of teamwork between the dog and his handler. The need for the handler to hack his dog in, or the need for excessive handling to keep the desired contact show poor cooperation. Both excessive dependence and excessive independence are indications of poor cooperation.
Pointing A pattern of rushing a stationary bird, attempting to catch the bird or avoiding the birds location in spite of ample exposure to birds are indications of pointing problems.
Behavior Notes Notes about behavior problem (specific type, age of onset, symptoms, treatment, outcome, etc.)