Health & Genetics Committee
Deceased Akita Survey Form

A short memoriam will be added to a dedicated page listing tributes to Akitas that have contributed.

Akita Name
Date of Birth
Date of Death
Place of Birth
Sex Male
Reason for Death - If euthanasia, please specify medical, trauma or behavioral condition - If old age related please say, old age. If stillborn, say, stillborn. Died within 7 days of birth, please say, fading puppy. Old Age 
Still Born 
Fading Puppy
         Medical Trauma Behavioral


Please list any chronic health conditions:
Please describe as completely as possible. Please use correct grammar, punctuation and don't use all caps or all small letters
Most commonly fed diet:

Commercial Kibble / Dry Dog Food 
Premium Kibble / Dry Dog Food
Canned Dog Food 
Raw Diet
Home Cooked Diet 
Other  If other, or a mixed diet please explain:

Supplements: (list 3 most commonly given) Supplement 1
Supplement 2
Supplement 3
Vaccine History:

All recommended vaccines per year
All recommended vaccines every other year
Vaccinated only as a puppy 
Rabies only
No vaccines ever 
Other vaccines given (Lymes, etc.) Please List:

Any vaccines not given, even though vaccinated regularly:
Most common vaccines used on a regular basis, or as recommended:
Reactions to any vaccination? Please list the vaccination and the reaction:
Would you like your Akita remembered on the Memorial Page listing Yes

Is there anything you feel would be helpful to the Genetic and Health Committee that was not asked in this form.



Updated on 09/18/2008