2300 E Nifong Blvd, Columbia, MO 65201-3806
Phone: (573) 442-0418; Fax: (573) 8785-5073
www.caninehealthinfo.org
Sponsored by /
Application for DNA Repository
(Lowchen Club of America DNA Collection Clinic)
Reduced Fee – $10 - the OFA will underwrite 50% of the costs on samples collected through 10/24/08
______/ ______Previous application number (if any) / Registration number q AKC q CKC q Other______
______/ ______
Registered name / Sex color
______/ ______
Breed / Date of birth (month-day-year)
______/ ______
ID number q Tattoo q Microchip / Registration # of sire registration # of dam
______/ ______
Owner name / Co-owner name
______/ ______
Street address / Owner email
______/ ______
City State/Province Zip/postal code / Owner phone
DNA Sample Submission Agreement
I hereby donate, assign, and transfer a DNA sample of the dog named above to the CHIC DNA Repository for research purposes and warrant my authority to do so. I understand that any future use or distribution of this DNA sample will be within the sole direction and authority of the CHIC DNA Repository. I authorize the OFA and the AKC CHF to provide any researchers receiving a portion of this sample with all necessary information including pedigree and health history to make the sample useful. My intent in providing this DNA sample is to further research into canine health issues. I hereby relinquish all rights to, and ownership of, the DNA sample.
Signature of owner/agent Date
Mission Statement
The CHIC DNA Repository, co-sponsored by the OFA and the AKC/CHF, collects and stores canine DNA samples along with corresponding genealogic and phenotypic information to facilitate future research and testing aimed at reducing the incidence of inherited disease in dogs.
Objectives
• Facilitate more rapid research progress by expediting the sample collection process
• Provide researchers with optimized family groups needed for research
• Allow breeders to take advantage of future DNA based disease tests as they become available
• Foster a team environment between breeders/owners and the research community improving the likelihood of genetic discovery
CHIC DNA Repository
Health Survey
Has this dog ever been diagnosed with any of the following health issues?
For each section you answer with a yes, please fill out the rest of the section. If you answer no to any section, skip to the next section.
Eye Disorders q Yes q No
q Distichiasis
q Dry Eye
q Entropian
q Juvenile Cataracts
q Non Healing Corneal Ulcer
q Retinal Dysplasia
q Persistent Pupillary Membrane
q Glaucoma
q Cherry Eye
q Other
Ear Disorders q Yes q No
q Chronic ear infection
q Deafness (if yes, describe coat color/pattern)
q Other
Skin Disorders q Yes q No
q Atopic Dermatitis (allergy to inhaled substances)
q Food/Medicine Allergies
q Alopecia
q Autoimmune Skin Disease
q Systemic Demodectic Mange
q Sebaceous adenitis
q Seborrhea
q Other
Gastrointestinal Disorders q Yes q No
q Pyloric Stenosis
q Megaesophagus
q Cleft Palate
q Chronic Vomiting
q Choric Colitis
q Inflammatory Bowel Disease
q Other
Respiratory Disorders q Yes q No
q Congenital Tracheal Stenosis (narrow trachea)
q Stenotic Nares
q Elongated Soft Palate
q Laryngeal Paralysis
q Other
Orthopedic Disorders q Yes q No
q Hip Dysplasia
q Patellar Luxation
q Elbow Dysplasia
q Premature IVD (intervertebral disc degeneration)
q Vertebral Anomalies
q HOD
q Other
Cardiac Disorders q Yes q No
q Vascular Ring (right aortic arch)
q Subaortic Stenosis
q Pulmonic Valve Stenosis
q Persistent Ductus Arteriosus
q Persistent Foramen Ovale
q Tricuspid Valve Defect
q Mitral Valve Defect
q Cardiomyopathy
q Porto-Systemic Vascular Shunt (Liver Shunt)
q Other
Urinary Disorders q Yes q No
q Ectopic Ureter
q Urinary Crystals / Stones
q Other
Blood/Lymph Disorders q Yes q No
q Autoimmune Hemolytic Anemia
q Hemophilia (Type A or B)
q Idiopathic Thrombocytopenia
q vonWillebrand’s disease (Symptomatic?)
q Other
Endocrine Disorders q Yes q No
q Hypothyroid
q Addison’s disease (adrenal insufficiency)
q Cushing’s disease (adrenal oversecretion)
q Diabetes
q Other
Reproductive Disorders q Yes q No
q Cryptorchid/Monorchid
q Abnormal Sperm
q Testicular Atrophy
q Irregular heat cycle
q Uterine Inertia
q Other
Neurologic Disorders q Yes q No
q Epilepsy
q Caudea Equina Syndrome
q Degenerative Myelopathy
q Other
Cancer/Tumors q Yes q No
q Mast cell tumor
q Lymphoma
q Hemangiosarcoma
q Testicular cancer
q Mammary cancer
q Osteosarcoma
q Other