First Name* must provide value

Last Name* must provide value

Phone Number

Email Address

State of Address: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA ME MD MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY

Today's Date
Today M-D-Y

What is your pet's call name?* must provide value

Does your pet have an AKC-registered name?* must provide value

Yes

No

What is your pet's AKC-registered name?

What is your pet's breed?* must provide value

Samoyed Samoyed mix Australian Terrier Australian Terrier mix Pug Pug mix American Eskimo American Eskimo mix Mixed breed Other pure breed German Shepherd German Shepherd mix Golden Retriever Golden Retriever mix American Pit Bull Terrier American Pit Bull Terrier mix Labrador Retriever Labrador Retriever mix

What is your pet's breed?

What is your pet's date of birth (approximate if unknown)?* must provide value

Today M-D-Y

What is your pet's age today? Less than 6 months old 6 months to 1 year old 1 year 1 month 1 year 2 months 1 year 3 months 1 year 4 months 1 year 5 months 1 year 6 months 1 year 7 months 1 year 8 months 1 year 9 months 1 year 10 months 1 year 11 months 2 years 2 years 1 month 2 years 2 months 2 years 3 months 2 years 4 months 2 years 5 months 2 years 6 months 2 years 7 months 2 years 8 months 2 years 9 months 2 years 10 months 2 years 11 months 3 years 3 years 1 month 3 years 2 months 3 years 3 months 3 years 4 months 3 years 5 months 3 years 6 months 3 years 7 months 3 years 8 months 3 years 9 months 3 years 10 months 3 years 11 months 4 years 4 years 1 month 4 years 2 months 4 years 3 months 4 years 4 months 4 years 5 months 4 years 6 months 4 years 7 months 4 years 8 months 4 years 9 months 4 years 10 months 4 years 11 months 5 years 5 years 1 month 5 years 2 months 5 years 3 months 5 years 4 months 5 years 5 months 5 years 6 months 5 years 7 months 5 years 8 months 5 years 9 months 5 years 10 months 5 years 11 months 6 years 6 years 1 month 6 years 2 months 6 years 3 months 6 years 4 months 6 years 5 months 6 years 6 months 6 years 7 months 6 years 8 months 6 years 9 months 6 years 10 months 6 years 11 months 7 years 7 years 1 month 7 years 2 months 7 years 3 months 7 years 4 months 7 years 5 months 7 years 6 months 7 years 7 months 7 years 8 months 7 years 9 months 7 years 10 months 7 years 11 months 8 years 8 years 1 month 8 years 2 months 8 years 3 months 8 years 4 months 8 years 5 months 8 years 6 months 8 years 7 months 8 years 8 months 8 years 9 months 8 years 10 months 8 years 11 months 9 years 9 years 1 month 9 years 2 months 9 years 3 months 9 years 4 months 9 years 5 months 9 years 6 months 9 years 7 months 9 years 8 months 9 years 9 months 9 years 10 months 9 years 11 months 10 years 10 years 1 month 10 years 2 months 10 years 3 months 10 years 4 months 10 years 5 months 10 years 6 months 10 years 7 months 10 years 8 months 10 years 9 months 10 years 10 months 10 years 11 months 11 years 11 years 1 month 11 years 2 months 11 years 3 months 11 years 4 months 11 years 5 months 11 years 6 months 11 years 7 months 11 years 8 months 11 years 9 months 11 years 10 months 11 years 11 months 12 years 12 years 1 month 12 years 2 months 12 years 3 months 12 years 4 months 12 years 5 months 12 years 6 months 12 years 7 months 12 years 8 months 12 years 9 months 12 years 10 months 12 years 11 months 13 years 13 years 1 month 13 years 2 months 13 years 3 months 13 years 4 months 13 years 5 months 13 years 6 months 13 years 7 months 13 years 8 months 13 years 9 months 13 years 10 months 13 years 11 months 14 years 14 years 1 month 14 years 2 months 14 years 3 months 14 years 4 months 14 years 5 months 14 years 6 months 14 years 7 months 14 years 8 months 14 years 9 months 14 years 10 months 14 years 11 months 15 years 15 years 1 month 15 years 2 months 15 years 3 months 15 years 4 months 15 years 5 months 15 years 6 months 15 years 7 months 15 years 8 months 15 years 9 months 15 years 10 months 15 years 11 months 16 years 16 years 1 month 16 years 2 month 16 years 3 months 16 years 4 months 16 years 5 months 16 years 6 months 16 years 7 months 16 years 8 months 16 years 9 months 16 years 10 months 16 years 11 months 17 years 17 years 1 month 17 years 2 months 17 years 3 months 17 years 4 months 17 years 5 months 17 years 6 months 17 years 7 months 17 years 8 months 17 years 9 months 17 years 10 months 17 years 11 months 18 years 18 years 1 month 18 years 2 months 18 years 3 months 18 years 4 months 18 years 5 months 18 years 6 months 18 years 7 months 18 years 8 months 18 years 9 months 18 years 10 months 18 years 11 months 19 years Over 19 years old

What is your pet's sex? Intact male Intact female Neutered male Spayed female

What is your dog's approximate weight in pounds?

What diet (brand and/or type) are you feeding your dog?

Is your pet diabetic?* must provide value

Yes

No

Is your dog receiving insulin?* must provide value

Yes

No

Which type of insulin is your dog receiving?* must provide value

NPH / Humulin-N / Novolin-N Lantus / Glargine Vetsulin PZI Levemir / Detemir Other

What is the name of insulin which your dog is receiving?* must provide value

How many times a day does your dog receive insulin? Once daily Twice daily Three times daily

How many units of insulin does your dog receive with each injection? 1 units 2 units 3 units 4 units 5 units 6 units 7 units 8 units 9 units 10 units 11 units 12 units 13 units 14 units 15 units 16 units 17 units 18 units 19 units 20 units 21 units 22 units 23 units 24 units 25 units 26 units 27 units 28 units 29 units 30 units 31 units 32 units 33 units 34 units 35 units or more

When was your dog diagnosed with diabetes (approximate if unknown)?
Today M-D-Y

What is your veterinarian's name (if known)?

What is your veterinarian's phone number (if known)?

What were the clinical signs that you noticed when your dog was diagnosed with diabetes (if recallable)? Increased thirst or urination

Increased hunger

Weight loss

Has your dog been diagnosed with hypothyroidism? Yes

No

Is your dog being treated with thyroid supplementation? Yes

No

Has your dog been diagnosed with Addison's disease (hypoadrenocorticism)? Yes

No

Is your dog currently being treated with any of the following medications? Prednisone

DOCP

Prednisone and DOCP

Fludricortisone (e.g. Florinef)

Was the prednisone given before or after the diagnosis of diabetes? Before diagnosis of diabetes

After diagnosis of diabetes

How much prednisone (in mg) is given per dose (each time you give the medication)?

How many times per day do you give this prednisone dose? Once daily Twice daily Other

Does your dog have any other concurrent illnesses? Yes

No

Please list the concurrent conditions/illnesses.

Did you obtain your pet from a breeder? Yes

No

What is your pet's breeder's name (if known)?

What is your pet's breeder's phone number (if known)?

What is your pet's breeder's email?

Was your dog obtained from a rescue group? Yes

No

What is the name of your dog's rescue?

Are you in contact with the owner of your dog's mother? Yes

No

Who is the owner of your dog's mother (if known)?

What is this owner's email address (if known)?

What is the name of your dog's mother (if known)?

Is your dog's mother still alive (if known)? Yes No Unsure

Are you in contact with the owner of your dog's father? Yes

No

Who is the owner of your dog's father (if known)?

What is this owner's email address (if known)?

What is the name of your dog's father (if known)?

Is your dog's father still alive? Yes No Unsure

Does your dog have any littermates? Yes

No

Unknown

Are you able to give any information regarding your pet's littermates? Yes

No

How many littermates did your dog have?

What is the name(s) of your dog's littermates (list all that are known)?

What is the email address of the owner(s) of your dog's littermates (list all known)?

Does your dog have any full siblings (shares same father and mother) from a DIFFERENT litter(s)? Yes

No

Unknown

Are you able to give any information pertaining to these full siblings? Yes

No

Approximately how many other full siblings (from other litters) does your dog have? 1-5 6-10 11-15 16-20 Greater than 20

What is the name(s) of your dog's full siblings (list any that are known)

What is the email address of the owner(s) of your dog's full siblings (list if known):

Does your dog have any offspring? Yes

No

Unknown

How many litters did your pet produce?

Are you able to provide any information pertaining to your pet's offspring? Yes

No

What is the name(s) of your dog's offspring?

What is the email address of the owner(s) of your dog's offspring?

Are there any other dogs living in the household? Yes

No

How many other dogs live in the household? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Greater than 15

Are any of these household dogs diabetic? Yes

No

How many household dogs are diabetic? 1 2 3 4 5 Greater than 5

What is the diabetic household dog's call name?

Does THIS diabetic household dog have an AKC-registered name?* must provide value

Yes

No

What is THIS diabetic household dog's AKC-registered name?

What is THIS diabetic household dog's breed? Samoyed Samoyed mix Australian Terrier Australian Terrier mix Pug Pug mix American Eskimo American Eskimo mix Mixed breed Other pure breed German Shepherd German Shepherd mix Golden Retriever Golden Retriever mix American Pit Bull Terrier American Pit Bull Terrier mix Labrador Retriever Labrador Retriever mix

What is THIS diabetic household dog's breed?

What is THIS diabetic household dog's date of birth?
Today M-D-Y

What is THIS diabetic household dog's age today? Less than 6 months old 6 months to 1 year old 1 year 1 month 1 year 2 months 1 year 3 months 1 year 4 months 1 year 5 months 1 year 6 months 1 year 7 months 1 year 8 months 1 year 9 months 1 year 10 months 1 year 11 months 2 years 2 years 1 month 2 years 2 months 2 years 3 months 2 years 4 months 2 years 5 months 2 years 6 months 2 years 7 months 2 years 8 months 2 years 9 months 2 years 10 months 2 years 11 months 3 years 3 years 1 month 3 years 2 months 3 years 3 months 3 years 4 months 3 years 5 months 3 years 6 months 3 years 7 months 3 years 8 months 3 years 9 months 3 years 10 months 3 years 11 months 4 years 4 years 1 month 4 years 2 months 4 years 3 months 4 years 4 months 4 years 5 months 4 years 6 months 4 years 7 months 4 years 8 months 4 years 9 months 4 years 10 months 4 years 11 months 5 years 5 years 1 month 5 years 2 months 5 years 3 months 5 years 4 months 5 years 5 months 5 years 6 months 5 years 7 months 5 years 8 months 5 years 9 months 5 years 10 months 5 years 11 months 6 years 6 years 1 month 6 years 2 months 6 years 3 months 6 years 4 months 6 years 5 months 6 years 6 months 6 years 7 months 6 years 8 months 6 years 9 months 6 years 10 months 6 years 11 months 7 years 7 years 1 month 7 years 2 months 7 years 3 months 7 years 4 months 7 years 5 months 7 years 6 months 7 years 7 months 7 years 8 months 7 years 9 months 7 years 10 months 7 years 11 months 8 years 8 years 1 month 8 years 2 months 8 years 3 months 8 years 4 months 8 years 5 months 8 years 6 months 8 years 7 months 8 years 8 months 8 years 9 months 8 years 10 months 8 years 11 months 9 years 9 years 1 month 9 years 2 months 9 years 3 months 9 years 4 months 9 years 5 months 9 years 6 months 9 years 7 months 9 years 8 months 9 years 9 months 9 years 10 months 9 years 11 months 10 years 10 years 1 month 10 years 2 months 10 years 3 months 10 years 4 months 10 years 5 months 10 years 6 months 10 years 7 months 10 years 8 months 10 years 9 months 10 years 10 months 10 years 11 months 11 years 11 years 1 month 11 years 2 months 11 years 3 months 11 years 4 months 11 years 5 months 11 years 6 months 11 years 7 months 11 years 8 months 11 years 9 months 11 years 10 months 11 years 11 months 12 years 12 years 1 month 12 years 2 months 12 years 3 months 12 years 4 months 12 years 5 months 12 years 6 months 12 years 7 months 12 years 8 months 12 years 9 months 12 years 10 months 12 years 11 months 13 years 13 years 1 month 13 years 2 months 13 years 3 months 13 years 4 months 13 years 5 months 13 years 6 months 13 years 7 months 13 years 8 months 13 years 9 months 13 years 10 months 13 years 11 months 14 years 14 years 1 month 14 years 2 months 14 years 3 months 14 years 4 months 14 years 5 months 14 years 6 months 14 years 7 months 14 years 8 months 14 years 9 months 14 years 10 months 14 years 11 months 15 years 15 years 1 month 15 years 2 months 15 years 3 months 15 years 4 months 15 years 5 months 15 years 6 months 15 years 7 months 15 years 8 months 15 years 9 months 15 years 10 months 15 years 11 months 16 years 16 years 1 month 16 years 2 month 16 years 3 months 16 years 4 months 16 years 5 months 16 years 6 months 16 years 7 months 16 years 8 months 16 years 9 months 16 years 10 months 16 years 11 months 17 years 17 years 1 month 17 years 2 months 17 years 3 months 17 years 4 months 17 years 5 months 17 years 6 months 17 years 7 months 17 years 8 months 17 years 9 months 17 years 10 months 17 years 11 months 18 years 18 years 1 month 18 years 2 months 18 years 3 months 18 years 4 months 18 years 5 months 18 years 6 months 18 years 7 months 18 years 8 months 18 years 9 months 18 years 10 months 18 years 11 months 19 years Over 19 years old

What is THIS diabetic household dog's sex? Intact male Intact female Neutered male Spayed female

What is THIS diabetic household dog's approximate weight in pounds?

What diet (brand and type) are you feeding THIS diabetic household dog?

Is THIS diabetic household dog receiving insulin? Yes

No

Which type of insulin is THIS diabetic household dog receiving? NPH / Humulin-N / Novolin-N Lantus / Glargine Vetsulin PZI Levemir / Detemir Other

What is the name of insulin which THIS diabetic household dog is receiving?

How many times a day does THIS household dog receive insulin? Once daily Twice daily Three times daily

How many units of insulin does THIS household dog receive with each injection? 1 units 2 units 3 units 4 units 5 units 6 units 7 units 8 units 9 units 10 units 11 units 12 units 13 units 14 units 15 units 16 units 17 units 18 units 19 units 20 units 21 units 22 units 23 units 24 units 25 units 26 units 27 units 28 units 29 units 30 units 31 units 32 units 33 units 34 units 35 units or more

When was THIS diabetic household dog diagnosed with diabetes (approximate if unknown)?
Today M-D-Y

What is the second diabetic household dog's call name?

What is THIS diabetic household dog's AKC-registered name?

What is THIS diabetic household dog's breed? Samoyed Samoyed mix Australian Terrier Australian Terrier mix Pug Pug mix American Eskimo American Eskimo mix Mixed breed Other pure breed German Shepherd German Shepherd mix Golden Retriever Golden Retriever mix American Pit Bull Terrier American Pit Bull Terrier mix Labrador Retriever Labrador Retriever mix

What is THIS diabetic household dog's date of birth?
Today M-D-Y

What is THIS diabetic household dog's age today? Less than 6 months old 6 months to 1 year old 1 year 1 month 1 year 2 months 1 year 3 months 1 year 4 months 1 year 5 months 1 year 6 months 1 year 7 months 1 year 8 months 1 year 9 months 1 year 10 months 1 year 11 months 2 years 2 years 1 month 2 years 2 months 2 years 3 months 2 years 4 months 2 years 5 months 2 years 6 months 2 years 7 months 2 years 8 months 2 years 9 months 2 years 10 months 2 years 11 months 3 years 3 years 1 month 3 years 2 months 3 years 3 months 3 years 4 months 3 years 5 months 3 years 6 months 3 years 7 months 3 years 8 months 3 years 9 months 3 years 10 months 3 years 11 months 4 years 4 years 1 month 4 years 2 months 4 years 3 months 4 years 4 months 4 years 5 months 4 years 6 months 4 years 7 months 4 years 8 months 4 years 9 months 4 years 10 months 4 years 11 months 5 years 5 years 1 month 5 years 2 months 5 years 3 months 5 years 4 months 5 years 5 months 5 years 6 months 5 years 7 months 5 years 8 months 5 years 9 months 5 years 10 months 5 years 11 months 6 years 6 years 1 month 6 years 2 months 6 years 3 months 6 years 4 months 6 years 5 months 6 years 6 months 6 years 7 months 6 years 8 months 6 years 9 months 6 years 10 months 6 years 11 months 7 years 7 years 1 month 7 years 2 months 7 years 3 months 7 years 4 months 7 years 5 months 7 years 6 months 7 years 7 months 7 years 8 months 7 years 9 months 7 years 10 months 7 years 11 months 8 years 8 years 1 month 8 years 2 months 8 years 3 months 8 years 4 months 8 years 5 months 8 years 6 months 8 years 7 months 8 years 8 months 8 years 9 months 8 years 10 months 8 years 11 months 9 years 9 years 1 month 9 years 2 months 9 years 3 months 9 years 4 months 9 years 5 months 9 years 6 months 9 years 7 months 9 years 8 months 9 years 9 months 9 years 10 months 9 years 11 months 10 years 10 years 1 month 10 years 2 months 10 years 3 months 10 years 4 months 10 years 5 months 10 years 6 months 10 years 7 months 10 years 8 months 10 years 9 months 10 years 10 months 10 years 11 months 11 years 11 years 1 month 11 years 2 months 11 years 3 months 11 years 4 months 11 years 5 months 11 years 6 months 11 years 7 months 11 years 8 months 11 years 9 months 11 years 10 months 11 years 11 months 12 years 12 years 1 month 12 years 2 months 12 years 3 months 12 years 4 months 12 years 5 months 12 years 6 months 12 years 7 months 12 years 8 months 12 years 9 months 12 years 10 months 12 years 11 months 13 years 13 years 1 month 13 years 2 months 13 years 3 months 13 years 4 months 13 years 5 months 13 years 6 months 13 years 7 months 13 years 8 months 13 years 9 months 13 years 10 months 13 years 11 months 14 years 14 years 1 month 14 years 2 months 14 years 3 months 14 years 4 months 14 years 5 months 14 years 6 months 14 years 7 months 14 years 8 months 14 years 9 months 14 years 10 months 14 years 11 months 15 years 15 years 1 month 15 years 2 months 15 years 3 months 15 years 4 months 15 years 5 months 15 years 6 months 15 years 7 months 15 years 8 months 15 years 9 months 15 years 10 months 15 years 11 months 16 years 16 years 1 month 16 years 2 month 16 years 3 months 16 years 4 months 16 years 5 months 16 years 6 months 16 years 7 months 16 years 8 months 16 years 9 months 16 years 10 months 16 years 11 months 17 years 17 years 1 month 17 years 2 months 17 years 3 months 17 years 4 months 17 years 5 months 17 years 6 months 17 years 7 months 17 years 8 months 17 years 9 months 17 years 10 months 17 years 11 months 18 years 18 years 1 month 18 years 2 months 18 years 3 months 18 years 4 months 18 years 5 months 18 years 6 months 18 years 7 months 18 years 8 months 18 years 9 months 18 years 10 months 18 years 11 months 19 years Over 19 years old

What is THIS diabetic household dog's sex? Intact male Intact female Neutered male Spayed female

What is THIS diabetic household dog's approximate weight in pounds?

What diet (brand and type) are you feeding THIS diabetic household dog?

Is THIS diabetic household dog receiving insulin? Yes

No

Which type of insulin is THIS diabetic household dog receiving? NPH / Humulin-N / Novolin-N Lantus / Glargine Vetsulin PZI Levemir / Detemir Other

What is the name of insulin which THIS diabetic household dog is receiving?

How many times a day does THIS household dog receive insulin? Once daily Twice daily Three times daily

How many units of insulin does THIS household dog receive with each injection? 1 units 2 units 3 units 4 units 5 units 6 units 7 units 8 units 9 units 10 units 11 units 12 units 13 units 14 units 15 units 16 units 17 units 18 units 19 units 20 units 21 units 22 units 23 units 24 units 25 units 26 units 27 units 28 units 29 units 30 units 31 units 32 units 33 units 34 units 35 units or more

When was THIS diabetic household dog diagnosed with diabetes (approximate if unknown)?
Today M-D-Y

What is the third diabetic household dog's call name?

What is THIS diabetic household dog's AKC-registered name?

What is THIS diabetic household dog's breed? Samoyed Samoyed mix Australian Terrier Australian Terrier mix Pug Pug mix American Eskimo American Eskimo mix Mixed breed Other pure breed German Shepherd German Shepherd mix Golden Retriever Golden Retriever mix American Pit Bull Terrier American Pit Bull Terrier mix Labrador Retriever Labrador Retriever mix

What is THIS diabetic household dog's date of birth?
Today M-D-Y

What is THIS diabetic household dog's age today? Less than 6 months old 6 months to 1 year old 1 year 1 month 1 year 2 months 1 year 3 months 1 year 4 months 1 year 5 months 1 year 6 months 1 year 7 months 1 year 8 months 1 year 9 months 1 year 10 months 1 year 11 months 2 years 2 years 1 month 2 years 2 months 2 years 3 months 2 years 4 months 2 years 5 months 2 years 6 months 2 years 7 months 2 years 8 months 2 years 9 months 2 years 10 months 2 years 11 months 3 years 3 years 1 month 3 years 2 months 3 years 3 months 3 years 4 months 3 years 5 months 3 years 6 months 3 years 7 months 3 years 8 months 3 years 9 months 3 years 10 months 3 years 11 months 4 years 4 years 1 month 4 years 2 months 4 years 3 months 4 years 4 months 4 years 5 months 4 years 6 months 4 years 7 months 4 years 8 months 4 years 9 months 4 years 10 months 4 years 11 months 5 years 5 years 1 month 5 years 2 months 5 years 3 months 5 years 4 months 5 years 5 months 5 years 6 months 5 years 7 months 5 years 8 months 5 years 9 months 5 years 10 months 5 years 11 months 6 years 6 years 1 month 6 years 2 months 6 years 3 months 6 years 4 months 6 years 5 months 6 years 6 months 6 years 7 months 6 years 8 months 6 years 9 months 6 years 10 months 6 years 11 months 7 years 7 years 1 month 7 years 2 months 7 years 3 months 7 years 4 months 7 years 5 months 7 years 6 months 7 years 7 months 7 years 8 months 7 years 9 months 7 years 10 months 7 years 11 months 8 years 8 years 1 month 8 years 2 months 8 years 3 months 8 years 4 months 8 years 5 months 8 years 6 months 8 years 7 months 8 years 8 months 8 years 9 months 8 years 10 months 8 years 11 months 9 years 9 years 1 month 9 years 2 months 9 years 3 months 9 years 4 months 9 years 5 months 9 years 6 months 9 years 7 months 9 years 8 months 9 years 9 months 9 years 10 months 9 years 11 months 10 years 10 years 1 month 10 years 2 months 10 years 3 months 10 years 4 months 10 years 5 months 10 years 6 months 10 years 7 months 10 years 8 months 10 years 9 months 10 years 10 months 10 years 11 months 11 years 11 years 1 month 11 years 2 months 11 years 3 months 11 years 4 months 11 years 5 months 11 years 6 months 11 years 7 months 11 years 8 months 11 years 9 months 11 years 10 months 11 years 11 months 12 years 12 years 1 month 12 years 2 months 12 years 3 months 12 years 4 months 12 years 5 months 12 years 6 months 12 years 7 months 12 years 8 months 12 years 9 months 12 years 10 months 12 years 11 months 13 years 13 years 1 month 13 years 2 months 13 years 3 months 13 years 4 months 13 years 5 months 13 years 6 months 13 years 7 months 13 years 8 months 13 years 9 months 13 years 10 months 13 years 11 months 14 years 14 years 1 month 14 years 2 months 14 years 3 months 14 years 4 months 14 years 5 months 14 years 6 months 14 years 7 months 14 years 8 months 14 years 9 months 14 years 10 months 14 years 11 months 15 years 15 years 1 month 15 years 2 months 15 years 3 months 15 years 4 months 15 years 5 months 15 years 6 months 15 years 7 months 15 years 8 months 15 years 9 months 15 years 10 months 15 years 11 months 16 years 16 years 1 month 16 years 2 month 16 years 3 months 16 years 4 months 16 years 5 months 16 years 6 months 16 years 7 months 16 years 8 months 16 years 9 months 16 years 10 months 16 years 11 months 17 years 17 years 1 month 17 years 2 months 17 years 3 months 17 years 4 months 17 years 5 months 17 years 6 months 17 years 7 months 17 years 8 months 17 years 9 months 17 years 10 months 17 years 11 months 18 years 18 years 1 month 18 years 2 months 18 years 3 months 18 years 4 months 18 years 5 months 18 years 6 months 18 years 7 months 18 years 8 months 18 years 9 months 18 years 10 months 18 years 11 months 19 years Over 19 years old

What is THIS diabetic household dog's sex? Intact male Intact female Neutered male Spayed female

What is THIS diabetic household dog's approximate weight in pounds?

What diet (brand and type) are you feeding THIS diabetic household dog?

Is THIS diabetic household dog receiving insulin? Yes

No

Which type of insulin is THIS diabetic household dog receiving? NPH / Humulin-N / Novolin-N Lantus / Glargine Vetsulin PZI Levemir / Detemir Other

What is the name of insulin which THIS diabetic household dog is receiving?

How many times a day does THIS household dog receive insulin? Once daily Twice daily Three times daily

How many units of insulin does THIS household dog receive with each injection? 1 units 2 units 3 units 4 units 5 units 6 units 7 units 8 units 9 units 10 units 11 units 12 units 13 units 14 units 15 units 16 units 17 units 18 units 19 units 20 units 21 units 22 units 23 units 24 units 25 units 26 units 27 units 28 units 29 units 30 units 31 units 32 units 33 units 34 units 35 units or more

When was THIS diabetic household dog diagnosed with diabetes (approximate if unknown)?
Today M-D-Y

Are you aware of a deceased diabetic dog that was directly related to the dog in this survey? Yes

No

Would you like to share information regarding this deceased diabetic dog? Yes

No

What was this deceased diabetic dog's call name?

Did this deceased diabetic dog have an AKC-registered name? Yes

No

What was this deceased diabetic dog's AKC-registered name?

What was this deceased diabetic dog's breed? Samoyed Samoyed mix Australian Terrier Australian Terrier mix Pug Pug mix American Eskimo American Eskimo mix Mixed breed Other pure breed German Shepherd German Shepherd mix Golden Retriever Golden Retriever mix American Pit Bull Terrier American Pit Bull Terrier mix Labrador Retriever Labrador Retriever mix

What was this deceased diabetic dog's breed?

What was this deceased diabetic dog's sex? Intact male Intact female Neutered male Spayed female

What was this deceased diabetic dog's date of birth (approximate if unknown)?
Today M-D-Y

When did this diabetic dog become deceased (approximate if unknown)?
Today M-D-Y

When was this deceased diabetic dog diagnosed with diabetes (approximate if unknown)?
Today M-D-Y

Approximately how much did this deceased diabetic dog weigh in pounds (at adulthood)?

Which type of insulin did this deceased diabetic dog receive? NPH / Humulin-N / Novolin-N Lantus / Glargine Vetsulin PZI Levemir / Detemir Other Unknown

What is the name of the insulin that this deceased diabetic dog received?

How many times a day did this deceased diabetic dog receive insulin? Once daily Twice daily Three times daily Unknown

How many units of insulin did this deceased diabetic dog receive with each injection? 1 units 2 units 3 units 4 units 5 units 6 units 7 units 8 units 9 units 10 units 11 units 12 units 13 units 14 units 15 units 16 units 17 units 18 units 19 units 20 units 21 units 22 units 23 units 24 units 25 units 26 units 27 units 28 units 29 units 30 units 31 units 32 units 33 units 34 units 35 units or more Unknown

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