Standard Poodle Cancer Registry

 

The fields marked in red must have some data entered. All others may be regarded as optional.

Dog's registered name
Registration number	Color
Date of birth (mon/day/year)	Sex   Male - neuteredFemale - spayedMale - intactFemale - intact
Sire's registered name
Dam's registered name
Note: Because poodles are not listed by variety, stud book numbers are useful for tracing pedigrees (AKC dogs only). If you cannot provide a pedigree (see below), do you have the stud book numbers of the sire and dam? They appear on official AKC registration papers after the registration # - e.g. Ima Great Dawg PP274902/03 11-91 Sire's #     Dam's #
Type of cancer
Age at onset	01234567891011121314151617 years   01234567891011 months
Stage at diagnosis	confined to a single sitespread to adjacent tissuesto lymph nodesdistant metastasisother
Initial symptoms
Current status	in remissionunder treatmentdeceasedother
Age at death (if applicable)	alive01234567891011121314151617 years   n/a01234567891011 months
Briefly describe treatment Additional comments

Do you have a multi-generation pedigree you would be willing to provide, if requested?	No3 generation4 generation5 generation
I certify that I am the BreederOwnerBreeder/owner of the dog named above.
May we contact you for additional information, if necessary?   Yes No (check one)
Your email address

Thank you for participating in our survey. All information that is submitted for this study goes directly to Lynne Wilkes and will be kept strictly confidential.

If any problems are encountered sending this form, data many be sent directly to Lynne Wilkes or The Canine Diversity Project, Department of Biology, University of Ottawa, Ottawa ON K1N 6N5, Canada.

Revised August 07, 2002