CTCA Health Test Form

DATE of Exam: __________________

Official Name of Dog: (print)

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Owners's Name: _________________________________________

Phone#: __________________________________

Email: ___________________________________

CTCA Registration Number: ________

GENERAL OFFICE EXAM, Form 2 of 3

July 8th, 2010

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TO: The EXAMINING VETERINARIAN

You may dictate your findings on this examination to either a staff member or your client. If your findings are unremarkable and within normal limits for a category, you need not write more than "WNL". Please note that we require your signature at the end of this form. Also, please attach a business card or letterhead just in case there is any reason we need to contact you. Should you want to contact us, please call (607) 693-2828 anytime. Once again, thank you so much for your help.

Sincerely, Robert Jay Russell, Ph.D. (CTCA President)

Please describe any deviations from normal structure or function when observing the following in this dog (if normal, please indicate, e.g., "WNL"):

1. VISION (Does this dog show any symptoms of blindness or Cherry Eye?):

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2. RETINA (Normal? Excess folding? Clear macular region? Do you feel that this dog should be evaluated by a veterinary Board-Certified Ophthalmologist?):

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3. HEART (normal rhythm? murmur? - specify "grade/VI"): _______________________

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4. LUNGS (clear? nasal discharge?): _________________________________________

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5. TESTES (both testes descended? normal prostate?): __________________________

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6. VULVA (normal size and opening?): _______________________________________

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7. UMBILICAL HERNIA (Does this dog have a hernia? How large is it [estimate in mm]? Is it a fat bleb or does it contain guts?): ____________________________________

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8. BITE (wry bite? scissors? pincer? cross bite? If undershot or overshot, do the upper and lower incisors touch when closing?: ________________________________________

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9. TEETH (all present? If some are missing, which ones?): ________________________

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10. SKIN and HAIR (any alopecia? seborrhea? indications of Demodex?):

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11. NOSE PIGMENT (mottled? Pied? Pink? Brown? Black?): ____________________

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12. EYE RING PIGMENT (Pink? Brown? Complete? If not, please describe gaps.)

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13. FORELIMB STRUCTURE (Out at elbows? In at elbows? Do the feet turn out excessively or face in (medially)? Any indication of pain in movement?): ______________

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14. HINDLIMB STRUCTURE (Out at knee? [i.e., excessive lateral rotation] In at knee? Do the feet turn out excessively or face in (medially)? Any indication of pain in movement?) Note that MILD cowhocks are desirable for proper motion in this breed:

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15. PATELLAs (Any indications of actual patellar luxation or pain? How easily can the patellas be luxated on palpation [i.e., scale of 0 to IV]? Do you feel this dog should be examined by a Board Certified Veterinary Orthopedist?):

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16. HIPs (Any indications of pain, crepitous, arthritis, Hip Dysplasia or Legg-Calves-Perthes disease? How lax are these hips? Do you feel this dog should be examined by a Board Certified Veterinary Orthopedist?):

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17. TEMPERAMENT (In your opinion, is this dog excessively fearful? dominant? aggressive? Did you observe any indications of dog aggressive or people aggressive behavior? Do you feel this dog should be examined by a Behavioral Specialist?)

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18. HOW LONG IS THIS DOG? [Please measure using a flexible tape from a point between the shoulder blades (e.g., the withers) to the anus--using the angle between the tail and the pelvis at the base of the tail as a reference point].

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19. HOW TALL IS THIS DOG? [Please measure by allowing the dog to assume a more-or-less relaxed stance, then measure the distance between the top of the withers and the ground. Use two rulers, one placed across the dog's shoulder area, the other then measuring the height of the first ruler. Try to keep the ruler that lies across the shoulder parallel to the ground while keeping both rulers at a 90 degree angle with respect to one another.]

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20. HOW HEAVY IS THIS DOG? _________________________________

21. ARE YOU TREATING this dog for any condition? Is it on medications? Is there anything else you think we should know as we evaluate this dog as a possibly BREEDABLE Coton de Tulear? Thank you for your good work.

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SIGNATURE of EXAMINING VETERINARIAN

TO THE APPLICANT: Any falsification of these tests may result in your immediate and permanent expulsion from the CTCA, the reclassification of your dogs or possibly the removal of your dogs and their progeny from the CTCA's database.