Degenerative Myelopathy Health Update Form

Thank you for providing samples to the Broad Institute for our research into Degenerative Myelopathy. Please take a few moments to fill out the form below, as the information will greatly help our research (if you prefer to print out and mail us a copy, please click here.) If your dog did not have Degenerative Myopathy, please click here for our general health update forms.

General questions

Name of Owner:

Dog's Call Name:

Dog's Registered Name:

Registration Number:

Dog's Sex:

Male

Female

Dog's Date of Birth:

Degenerative Myelopathy Questions:

Has your dog been diagnosed with Denerative Myelopathy (DM, aka ALS?):

Yes

No

Was DM in your dog diagnosed by a veterinarian?:

Yes

No

What was the date that your dog began showing signs of DM?:

Is your dog still alive?:

Yes

No

If NO, when did your dog die?:

What was the cause of death?:

How long has your dog been showing signs of DM?:

Please describe the FIRST symptoms of DM in your dog (please click all that apply)::

Other symptom (please specify)::

When (approximate date) was your dog unable to stand in the hind limbs and needed assistance walking?:

When (approximate date) did your dog have difficulty walking in the front limbs?:

Do you know of relatives of your dog who are diagnosed with Degenerative Myelopathy? :

Yes

No

If yes, please check all that apply::

Sire

Dam

Sibling

Grandparent

Other family member (please specify):

If you did not provide a pedigree copy with the original sample, please send a copy of the pedigree if it is available.:

Please feel free to provide any other information you feel would be usefule for the researchers below::