Border Terrier Breed Health Survey

Border Terrier Breed Health Group

Breed Health Survey
It is important that a separate report is given for each dog - please report on ALL of your Dogs, even if they are perfectly healthy. It is equally important to have confirmation that a Dog is healthy as well as reports of Dogs with established problems.

Forms are received by Dr. E Houston, Breed Health Co-ordinator

Once submitted you will receive a confirmation email with the details entered,

Please take a few minutes to complete this Health Survey
Dog's Details

* indicates required field
Pet Name *
Date of Birth *

Day Month Year
Date Date Picker Icon
Sex *

Male Female
Colour *
Entire/ Neutered *

Entire Neutered
Dog's Kennel Club Registered Name (if known)
Sire
KC Registered Name of Sire
Dam
KC Registered Name of Dam
Q1. Is your dog vaccinated? *

Regularly Occasionally Never
Last Vaccination Date *

Day Month Year
Date Date Picker Icon
Vaccine Brand *
Q2. Is your dog generally *

Healthy Not Healthy
Q3. Does your dog receive regular medication to prevent parasites(e.g. fleas and worms) ? *

Yes No
If you have answered Yes - then please indicate what medication and how often?
Medication *
Frequency *
Q4. Has your dog any obvious defects? *

Yes No
What type of defect? *

Teeth or Mouth Undescended Testicles - one Undescended Testicles - both Kinked Tail Blindness Other
Teeth or Mouth defect - please describe *
Please give a brief description of any defect
Q5. Has your dog any chronic problem that is distressing or affects its health or welfare? *

Yes No
Please briefly describe the problem (email copy of separate sheet or papers if necessary) – If your vet has given a diagnosis please state what it is *
Veterinary Diagnosis
Is your dog on long term medication for this condition? *

Yes No
What is the treatment? *
Q6. Has your dog ever required surgery? (other than routine neutering) *

Yes No
What was the reason? *
Was the surgery successful? *

Yes No Partially
Is there any long-term treatment required? *

Yes No
Please state the treatment *
Q7. Has your dog any unusual or undesirable behaviour problems? *

Yes No
Please tick if appropriate *

Aggression Timid Poor house training Destructive Fits or seizures Other
Other - Please describe *
Q8. Are there any other problems you wish to remark upon that are not covered by the questions so far? *

Yes No
If Yes then please describe *
Details of Owner
Name *

First Name (s) Last Name(s)

Address *

Street Address
Street Address Line 2
City	County
Postal Code	Country

E-mail *
Phone Number

Area Code Phone Number
Enter the message as it's shown *
Please note information provided will be used for analysis by the Border Terrier Breed Health Group. We use Jotform for this form.
Should be Empty:

Border Terrier Breed Health Group

Dog's Details

Details of Owner