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Tibetan Mastiff Thyroid Panel Survey

Please fill in this easy online survey for each of your Tibetan Mastiffs that have had a thyroid test performed. You should be able to get a copy of the test results from your vet's office, if you have not already done so. It is the mission of this committee to help discover the realistic testing range for the TM, as well as discover whether any common denominators exist, that we can project back to the membership. If you have any questions concerning this survey, please contact Cheryl Novak of the ATMA Health Committee at cnowak@unr.edu. Thank you!

What gender is your dog?		Female Male
Your dog is:		Spayed Neutered
If so, at what age?
What color is your dog?
What medication(s) does your TM routinely take?
Has your TM been diagnosed with any chronic health condition(s)? Yes No If so, explain:
Has your TM ever received treatment for a thyroid condition? Yes No
What was your TM's age at testing time for the thyroid activity you will list panel results for in this survey?
Was your TM's thyroid tested for breeding purposes? Yes No
Were there symptoms to give reason for doing a thyroid test? Yes No If yes, check the appropriate symptom(s) or add to the list below: Ear problems/infections Skin rashes/infections Overweight/sluggish Depressed Aggressive behavior Other reasons:
Were your dog's sire or dam tested before being bred? Sire: Yes No Don't know Dam: Yes No Don't know Were either the sire or dam tested at a low thyroid level? Sire: Yes No Don't know Dam: Yes No Don't know If your dog's sire or dam did not test low thyroid before breeding, did either one subsequently become low thyroid? Yes No At what age:
Where was the thyroid test performed for your TM? (a) In-house (eg: your vet's office): Yes No (b) National testing lab (eg: Michigan State University): Yes No If yes, which lab?
What thyroid test(s) were performed, and what were the resulting values? Basic blood panel, T4. Results: Full panel, which includes the following: cTSH (canine thyroid stimulating hormone) results T3 results T4 results Free T4D results TgAA (thyroglobulin autoantibodies) results
Do you know the cholesterol level of this dog? Yes No If so, please list the value:
Do you know the hemoglobin levels of this dog? Yes No If so, please list the value:
Do you know whether or not any of your TM's littermates have had thyroid problems? Yes No If yes, how many do you know of? If yes, what problems? If yes, what treatment was given?
Your Email Address (required field) Optional Information:* Owner's Name Dog's Name Dog's Sire Dog's Dam Dog's date of birth Additional comments, if any:

Thank You!