Can you help??????

Have you got a Shiba???????????

This is the J.S.I.C. BREED SURVEY QUESTIONNAIRE it can be saved to your pc by R Click save as a picture.

This info can be built up into a study of the problems in our breed and can only help in the long run. thank you .

DON'T LET THEM MAKE A DOCUMENTARY ON OUR BREED SAYING WE IGNORED THE PROBLEMS

iIf you have anything you want an answer to? or have any point you want to let us know about, then drop me a line

Japanese Shiba Inu Club of Great Britain– BREED SURVEY QUESTIONNAIRE

Additional forms can be obtained from the JSICGB Secretary

Or The Health Coordinator Mrs B Roskell

Report by

Mr/Mrs/Miss/Ms…………………………………………………………………………………

Address……..……………………………………………………………………………………

……..…………………………………………………………………………………………….

Post Code …..………………………Telephone Number

Registered Affix:…………………………………………………………………………………

Registered Name of dog  ……..…………………………………………………………………………..

Date of Birth…..…………………………………………………………………………………

KC Registration Number………………………………………………………………………

Has/has not been bred from……………………….Number of Litters……………………

My dog/bitch* has been

trouble free/suffered from* the following (please attach copies of any Veterinary       Report/Certificate where any conditions are being reported on this form).

1. Epilepsy                     Yes / No

2. Skin Conditions/  Allergies                 Yes / No

3. Glaucoma                   Yes / No

4. Other Eye Abnormalities             Yes / No

5. Heart Anomalies                                                                      Yes/ No

6. Luxating Patella’s                                                                    Yes / No

7. Other abnormality (space overleaf for further information)     Yes / No

8. Dog/Bitch holds a current BVA/KC Eye Test CertificateYes / No

    Gonioscopy/Glaucoma Test                                                                                      Pass /Fail

                                                                                                                                     

(The Breed Survey would be grateful for up-to-date copies of the BVA/KC eye testing  Certificates)

Dog or Bitch scored for HD (Hip Dysplasia)Yes / No

Age when scored :……………. Score Left:………………….. Score Right : …………….

Patella checked (we require a copy certificate)                                 Yes/No

Please complete the pedigree information on page two.

Please delete as appropriate.

I agree that the above information may be published by the Japanese Shiba Inu Club of  Great Britain. To the best of my knowledge and belief the above information is correct  and complete.

Signature……………………………………………..

Date…………………………………………………..

Japanese Shiba Inu Club of Great Britain – BREED SURVEY QUESTIONNAIRE

Page Two:  additional information and Pedigree

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PEDIGREE ______________________________________________________________________

Parents Grandparents Great Grandparents

Sire Sire Sire

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Dam

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                                               Dam Sire

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Dam

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Dam

________________________________________________________________________

Sire Sire Sire

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Dam

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                                               Dam Sire

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Dam

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Dam________________________________________________

Please Return the Completed Form to: -

Mrs B Roskell, 51 Talbot Road, Penwortham, Preston, Lancs, PR1 9QX

Health Coordinator