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Tube # ___________

For office use only

UNIVERSITY OF MINNESOTA Canine Pulmonary Fibrosis Genetic Study The University of Minnesota is performing a comprehensive research study in an effort to identify the genetic basis for the condition known as Pulmonary Fibrosis (PF). In dogs, this disorder has almost exclusively been seen in West Highland White Terriers. We are working to better characterize the syndrome and to develop a DNA test for diagnosis and pre-breeding screening. Dog Information Male

Breed Call Name

Birth Date

Reg. Name

Sire

Reg. #

Dam

Has this dog been diagnosed with Pulmonary Fibrosis?

Yes

Female

Intact

Date of Death

No

If yes, age of onset:

Owner Information Name

Phone

Street Address

Alt. Phone

City, State, Zip

Fax

Country

e-mail

Veterinarian Information Name

Phone

Clinic

Fax

Street Address

e-mail

City, State, Zip Country

Neutered/Spayed

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Dog Information, Medical Test Results Chest X-ray results (attach the discharge summary detailing X-ray findings) : Normal Abnormal Pulmonary Fibrosis Arterial Blood Gas (ABG) Please fill in values for ABG findings below or attach a copy of the test results.

37.0 °C

Patient Temperature P

pH

pHt

PaCO2

PaCO2t

PaO2

PaO2t

°F

HCO3 O2Sat

Dog Information, Health Questionnaire 1. How would you judge your dog's body condition right now? Obese, out of shape A little heavy, but in good shape In perfect condition Thin 2. Does your dog have a history of the following signs. Briefly detail in the right hand text box. Cyanosis (bluish coloring and/or pale gums) Lethargy Cough (nonproductive) Shortness of breath Increased respiratory rate and effort Open-mouth breathing Exercise Intolerance

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3. Has your dog ever been diagnosed with any of the following? Briefly detail in the right hand text box. Heart failure Cancer (specify type) Chronic bronchitis Other chronic conditions (eg. Diabetes, Addison's disease, Urinary stones, etc.)

4. Does your dog take a heartworm preventative? Yes No If yes, please indicate the brand of medication and date of last dose. Brand Date 5. Does this dog live in a smoking or non-smoking household? Non-smoking Smoking 6. Have you bred this dog?

Yes No If yes, have they produced PF to your knowledge?

Yes No Owner Consent I understand the above questions and have supplied complete and accurate information, to the best of my knowledge. I understand that this information will be available only to researchers directly involved in the study and that any publication (s) resulting from this research will refer to dogs by an anonymous code number only. I give the researchers directly involved in the study permission to contact my veterinarian(s) and to access information from my dog's medical record. I consent to the use of this information in this manner. Signed

Date

Print Form

UNIVERSITY OF MINNESOTA Pulmonary Fibrosis Submission Instructions Participation Criteria:

Cases • Dogs of any breed and any age that have a chest x-ray consistent with Pulmonary Fibrosis are eligible. Controls • Must be a purebred West Highland White Terrier • Must be a minimum of 8 years of age • Must have no history of persistent cough or other persistent respiratory signs • Must have either a normal chest x-ray and/or a normal arterial blood gas Sample Submission: • Complete the “Pulmonary Fibrosis Submission form”. • Make a copy of your dog's 3 or 5 generation pedigree (if available). • Make a copy of your dog's medical record (affected dogs). • Make a copy of the chest x-ray and/or arterial blood gas reports. • Collect a blood or tissue sample.

Blood

• Submit 5-10 cc's of whole blood in an EDTA tube(s) (Lavender-topped tube in the US). • Put the blood sample in the tubes and gently rock it a few times to distribute the anticoagulant: Do not spin, extract serum, or anything further. • Refrigerate if the sample is being held for any time before shipping.

Tissue (Deceased Dogs)

• If the dog dies before a blood sample can be collected, donating a small biopsy section will provide DNA for the research. • Place a 1 cm x 1 cm section of hair-free tissue (such as the inside of the cheek) into a labeled freezer bag. • Freeze if the sample is being held for an extended period of time before shipping.

Labeling

• Label the sample with the following: The dog's call name and the owner's last name.

Shipping

• Pack blood samples in a small box or insulated container (most veterinarians have these for shipping samples to labs). If the ambient temperature is > 80 F, pack samples with one or more cool packs. Tissue should always be sent with one or more cold packs. • Ideally, ship the sample immediately. • Ship to arrive within 2-5 days (US Mail, UPS, FedEx, etc.). Samples DO NOT need to be sent overnight. Whenever possible, do not send on a Friday. Typical shipping charges via USPS should be $5-10. • If the samples are held for a day or over the weekend, ideally, blood should be refrigerated and the tissue samples kept frozen. • Send samples with all forms to:

University of Minnesota c/o Katie Minor 1988 Fitch Ave 295 AS/VM St. Paul, MN 55108

If you have questions regarding sample submission please call 612-624-5322 or e-mail [email protected]