Breadcrumb Home Disease Research Dog Health Status Update Basic Info Today's date Owner's Last Name Owner's First Name Owner's Email Dog's Birth Date Dog's Call Name Dog's Registered Name Dog's Breed Coat Color Dog's AKC number Other Registering Organization ID # (if applicable) Disease information Addison's Disease Atophy Cancer Hemangiosarcoma Osteosarcoma Mast Cell Tumors Melanoma Mammary Tumors Lymphoma Other Cancers Please specify Cardiovascular Disease AVRC Dilated Cardiomyopathy Other Cardiovascular Diseases Please specify Degenerative Myelopathy** ** Please note we have a separate form specifically for dogs afflicted with Degenerative Myopathy, please see above for a link to that form. Demodikos Diabetes Epilepsy Exocrine Pancreatic Insufficiency Eye Disease Hypothyroidism Loss of Claws Obsessive Compulsive Disorder (OCD) Periodic Fever Pyometra Renal Disease Rheumatic Disease Other Please specify Date of Diagnosis Is your dog deceased? Date of Death Cause of Death I give the Broad Institute of MIT and Harvard permission to contact my veterinarian Yes No Please provide veterinarian contact information so that we may obtain further information about the diagnosis Is there any additional information that you'd like to provide us? If your dog has been diagnosed with any of the following diseases, please specify the date of diagnosis below.