How many Jack Russells have you owned and been in your possession since 1998 _________

What activities are you involved in with your Jack Russell Terriers?

Section One A: Lifespans:

1. At what age did you acquire your Jack Russell Terrier?__________________
2. From whom did you acquire your Jack Russell Terrier?

Breeder_______ Pet Shop_______ Rescue________ Gift________
3. Below please list the age and primary cause of death of the Jack Russell’s you have owned. ( If you need additional room please use the back of this page )

Section Two: Diet & Nutrition:

Section Three: Vaccinations & Flea Treatments:

1) How many puppy shots ( non-rabies – infectious diseases ) do you give by 16 weeks of age?
     Circle One number:   0    1    2    3    4

2) How often do you give adult boosters? Semi Annually Annual Other

3) How often do you vaccinate for Rabies? Annual Every Two Years Every Three years

4) Do you vaccinate your bitches prior to breeding them? Yes________ No_______

5) Do you vaccinate your own dogs? Yes___No___Or do use a Veterinarian?Yes___No___

6) Do you give heartworm medication? Yes_____ No_____

What brand?________________________________________________________________

7) Do you continue the use of heartworm medications when your bitch is in whelp?

Yes____________ No___________

8) What flea products do you use? ____________________________________

Answer only if you have bred one or more litters since 1998. If you have multiple breeding females; please list the answers to the following questions on the next page using an alphabetical letter to denote each female you own or have used in your breeding program.

1) How many litters have you bred? ____________________
2) At what age did your bitch have her first season?_________________
3) At what age did you first breed your bitch?______________________
4) How often does your bitch’s come in season?______________
5) How many puppies in the litter were born live?_______________
6) How many puppies were stillborn?______________
7) If your bitch has had multiple litters what was the largest litter size counting live births?_____________
8) What was the smallest litter size?_____________
9) How many breedings if any were unsuccessful?____________
10) Has your bitch ever had a Ceasarean section?___________At what age?_____________
11) Do you test for Brucellosis?__________________________
12) Has your bitch ever had a pyometra?________________At what age?_____________
13) Was your bitch spayed as a result of the pyometra?____________________________
14) What was the age of your bitch at the time of her last litter or breeding?__________
15) How many litters have you bred through:
      a) Natural Breeding?_____________
      b) Artificial Insemination – fresh semen?___________
      c) Artificial Insemination – fresh cooled?___________
      d) Artificial Insemination – frozen semen? ___________

16) What type of breeding do you use most frequently ? ( Circle One )
       Outcross       Linebreeding        Inbreeding        Combination Inbreeding & Linebreeding

17) Do you CERF test? Yes________ No________

a) How often do you CERF test?       Yearly       Every Two Years        Occasionally

18) Do you BAER test? Yes_________No________
19) Do you BAER & CERF test puppies before placing them in new homes? Yes___ No___
20) Do you radiograph hips? Yes_____ No_____
21) If so which method do you use?
      OFA_____ PennHip______ Both _______ At What age?_______
22) Do you have your puppies checked by a veterinarian before placing them? Yes____No____
Do you test for Luxating Patella’s Yes______No_____ Legge Perthes? Yes____ No____
Heart Murmurs? Yes______No______
24) What other testing if any do you do?
____________________________________________________________________________

Mouth & Teeth:

Overshot Bite:_____ Undershot Bite:_____ Missing Teeth:______ How Many Missing:______
Broken Teeth:______ Cracked Molars:_____ Cleft Palate:______ Gingivitus:_____
Malocclusion: ( teeth do not meet in front – wrye mouth )___________
Other (Explain):______________________________________________________________

Occular: ( Eyes )

Cataracts:_______ Type:___________ Age of dog at time of diagnosis:___________
Glaucoma:_______ Type:___________ Age of dog at time of diagnosis:________________
Lens Luxation________________ Age of dog at time of diagnosis:________________
PRA___________ Age of dog at time of diagnosis:________________
Corneal dystrophy:_____________ Age of dog at time of diagnosis:________________
Blocked Tear Ducts______________
Distichiasis:________________ Age of dog at time of diagnosis:_________________
Epithilial Dystrophy____________ Age of dog at time of diagnosis:_______________
Ectopic Cilia:_______________
Keratoconjunctivitis Sicca ( KCS): _______________
Other: ( Explain )_____________________________________________________________

Dermatology: ( Skin )

Demodectic mange:______ Persistent_______ Severe_______ Age of dog at time of diagnosis:_______
Sebaceous cysts:____________ Age of dog at time of diagnosis:________________
Pyoderma ( Skin Infection ):____________ Age of dog at time of diagnosis:________________
Black Hair Follicular Dysplasia:_________ Age of dog at time of diagnosis:________________
Ichthyosis:____________________ Age of dog at time of diagnosis:__________________
Pemphigus Foliaceus:________________ Age of dog at time of diagnosis:_____________
Seborrhea:_____________ Age of dog at time of diagnosis:________________
Hot Spots:_____________
Tumors:_______________ Age of dog at time of diagnosis:________________
Umbilical Hernia:____________
Inguinal Hernia:_____________
Other ( Explain ):_______________________________________________________________

Allergies

Atopic Dermatitis:_______ Inhalants:______ Food:_______ Contact:________ Flea:__________
Other ( Explain):__________________________________________________________________

Otic: ( Ears )

Deafness:_________ Age of dog when diagnosed:____________
Chronic Ear Infections:___________Age of dog when diagnosed:_____________

MusculoSkeletal System

Osteoarthritis ( Arthritis )___________ Age of dog at time of diagnosis:____________
Hip Dysplasia:___________ Age of dog at time of diagnosis:________________
Elbow Dysplasia:_________ Age of dog at time of diagnosis:________________
Luxating Patellas:_________Age of dog at time of diagnosis:________________
Panosteitis:_______________Age of dog at time of diagnosis:________________
Rheumatoid Arthritis:______Age of dog at time of diagnosis:________________
Disc Problems ( Explain ):__________________________________________________
Legge Perthes:_______________Age of dog at time of diagnosis:_________________
Scottie Cramp:______________Age of dog at time of diagnosis:_________________
Mitochondrial Myopathy: ______________Age of dog at time of diagnosis:____________
Cerebrospinal Demyelination:____________Age of dog at time of diagnosis:_________
Other ( Explain ):_______________________________________________________________

Neurology: ( Nervous System )

Tremors:___________ Age of dog at time of diagnosis:________________
Meningitis:_________ Age of dog at time of diagnosis:________________
Epilepsy:___________ Age of dog at time of diagnosis:________________
Cerebellar Degeneration:___________Age of dog at time of diagnosis:_________
Hereditary Ataxia:___________Age of dog at time of diagnosis:_________
Neuroxonal Dystrophy:__________ Age of dog at time of diagnosis:_________
Congenital Myasthenia Gravis:__________Age of dog at time of diagnosis:_________
Sensory Neuropathy_________________Age of dog at time of diagnosis:___________
Other ( Explain ):____________________________________________________________

Hematology: ( Blood )

Anemia:_____________ Age of dog at time of diagnosis:________________
Von Willebrand’s Disease:___________ Age of dog at time of diagnosis:___________
Clotting Disorders:____________ Age of dog at time of diagnosis:________________
Factor 10 Deficiency:____________Age of dog at time of diagnosis:_______________
Other ( Explain ):_______________________________________________________________

Cardiology: ( Heart )

Heart Murmurs:_________________ Age of dog at time of diagnosis:________________
Valve Dysfunction:_______________ Age of dog at time of diagnosis:________________
Congestive Heart Failure:_________ Age of dog at time of diagnosis:________________
PDA:______________Age of dog at time of diagnosis:________________________
Other ( Explain ):_______________________________________________________________

Respiratory

Epistaxis ( Nose Bleeds ):_______________
Bronchitis:______________
Other ( Explain ):_______________________________________________________________

Endocrinology:

Cushing’s Disease:______________ Age of dog at time of diagnosis:________________
Addison’s Disease:______________ Age of dog at time of diagnosis:________________
Hypothyroidism:________________ Age of dog at time of diagnosis:________________
Diabetes:______________ Age of dog at time of diagnosis:________________
Other ( Explain ):_______________________________________________________________

GastroIntestinal:

Inflammatory Bowel Disease:_______________ Age of dog at time of diagnosis:___________
Gastrinoma:________________ Age of dog at time of diagnosis:________________
Pancreatitis:________________ Age of dog at time of diagnosis:________________
Colitis:_______________ Age of dog at time of diagnosis:________________
Gall Stones:___________ Age of dog at time of diagnosis:________________
Gall Bladder Infection:_______________ Age of dog at time of diagnosis:________________
Hepatitis:_________________
Hepatitic Shunt:___________ Age of dog at time of diagnosis:________________
Portal Cabal Shunt:_________Age of dog at time of diagnosis:________________
Portal Systemic Shunt:_____________Age of dog at time of diagnosis:__________
Umbilical Hernia:____________
Inguinal Hernia:_____________
Cirrhosis:_________________ Age of dog at time of diagnosis:________________
Colitis:_________________ Age of dog at time of diagnosis:________________
Chronic Diarrhea:___________________
Obesity:___________________________
Peritonitis:________________Age of Onset:___________
Ulcers:________________Age of Onset:___________
Other ( Explain ):_______________________________________________________________

Kidney and Urinary:

Ectopic Ureters:_______________ Age of dog at time of diagnosis:________________
Incontinence:________________ Age of dog at time of diagnosis:________________
Kidney Stones:_______________ Age of dog at time of diagnosis:________________
Bladder Stones:_______________ Age of dog at time of diagnosis:________________
Prostate Infection:_____________ Age of dog at time of diagnosis:________________
Prostate Tumors:______________ Age of dog at time of diagnosis:________________
Other ( Explain ):_______________________________________________________________

Reproduction:

Male Problems:

Undescended Testicles: Cryptorchidism ( Both )______________
Monorchidism ( One )________________
Low Sperm Count or Motility:_____________
Infertility or Low Fertility:________________
Other ( Explain ):_______________________________________________________________

Female Problems:

Pyometria:_______________ Age of dog at time of diagnosis:_____________Spayed?_________
Metritis:____________________
Dystocia:_________________ Age of dog at time of diagnosis:________________
Infertility or Low Fertility:___________________
Abnormal Seasons:____________________
Mastitis:____________________
Other ( Explain ):_______________________________________________________________

Birth Defects of Puppies:

Stillborn Puppies:__________________
Herpes Virus ( Fading Puppies ):__________________
Puppies born with Rear Dewclaws:___________________
Umbilical Hernia:___________________
Neonatal Deaths ( birth to 10 weeks of age ):_______________
Other ( Explain ):_______________________________________________________________

Immune System:

Autoimmune Problems:__________________ Age of dog at time of diagnosis:______________
Inability to build Immunities:_____________ Age of dog at time of diagnosis:________________
Negative Reaction to Inoculations:_________
Other ( Explain ):_______________________________________________________________

Behavioral/Temperament Problems:

Aggressiveness towards people:___________Aggressiveness towards other dogs:___________
Shyness:________________
Fearfulness:_________________
Rage Syndrome:_________________
Submissive Urination:__________________
Phobias ( Explain):_____________________________________________________________
Others ( Explain ):_____________________________________________________________

Drug Reactions: ( Other than vaccines )

Any documented adverse reaction?
Specify Drug & Reaction:
________________________________________________________________
________________________________________________________________
________________________________________________________________

Vaccine Reactions:
Specify type of reaction and vaccine suspected:
________________________________________________________________
________________________________________________________________
________________________________________________________________

Other Disease’s. Comments or Questions: