Tube # ___________ For office use only

Calcium Oxalate Study Questionnaire 2 (for controls) ALL INFORMATION IS CONFIDENTIAL. Breed __________________________________________ Coat Color________________________________ Male / Female

Intact / Neutered

Registered Name _________________________________ Reg # ____________________________________ Birth Date ______________________________________ Call name: ________________________________ Sire: ___________________________________________ Dam:_____________________________________ Breeder’s City & State ____________________________

Owner Information and Consent Owner: Name _________________________________ Address _______________________________

Alternate _______________________ Contact

_______________________

City, State, Zip__________________________

_______________________

Phone (day) ____________________________

_______________________

Phone (eve) ____________________________

_______________________

Fax___________________________________

_______________________

e-mail ________________________________

_______________________

I submit this blood sample, pedigree, and/or questionnaire for the purpose of research. I understand that the identity of dogs and owners participating in the research will not be revealed; and I have supplied complete and accurate information, to the best of my knowledge. I give permission for the researchers to get additional medical information from my veterinarian.

Signed: ______________________________________

Date __________________

Dr. Eva Furrow at the U of MN is the contact for the heritability and genetics study taking place. If you have any questions about the study, please email [email protected] or call 612-624-6284. Fax forms to: 612-624-8779 attn Dr. Eva Furrow OR Mail forms to: University of Minnesota Veterinary Medical Center C/O Dr. Eva Furrow, Internal Medicine 1365 Gortner Ave St. Paul, MN 55108

Tube # ___________ For office use only

Note: This questionnaire is being used for the purpose of research. The identity of the dogs and owners participating in the research will not be revealed to anyone outside of the research group without express permission from the owner. CALCIUM OXALATE STUDY QUESTIONNAIRE 2

1. Has your dog had any other health problems either now or in the past?

2. Has your dog ever shown signs of a urinary problem (ex. blood in the urine, straining to urinate, urinating small amounts frequently, accidents in the house)? If so, please describe:

3. Is/was your dog on any medications? Please note specifically if your dog has ever received steroids (ex. prednisone, depomedrol, triamcinolone)?

4. Does your dog receive any nutritional supplements?

5. What is your dog’s diet?

6. Do you know of any related dogs (littermates, parents, etc) who have had urinary stones?

PLEASE INCLUDE A PEDIGREE FOR YOUR DOG.