QUESTIONNAIRE ANIMAL

Fill out the online questionnaire at your leisure and make sure that all information is correct.

1 IDENTIFICATION NUMBER:
2 QUESTIONNAIRE


PLEASE NOTE: Please use your Medicross order number as identification number.

In case you need to enter the information of an additional person in the online questionnaire or submission form for the same order, add “-2” to the identification number for an additional person, “-3” for the third person and so on. We ask you to carefully enter the mandatory data, because otherwise there may be delays in the process.

INFORMATION ABOUT THE ANIMAL

ANIMAL:
SEX:
PREGNANT:
CHECKHave you already carried out a same or different analysis at Medicross Group or are you currently having another analysis carried out

Please mark only what applies
1. Rarely 2. Moderately 3. Regularly

DETAILS
0123
Breed
Free outdoor movement
Castrated
FOOD
0123
Wet feed
Dried fodder
Fruit, vegetables
Herbs

Please mark complaints by severity only
1. Slight/Rarely 2. Moderate/Moderately 3. Strong/Regularly

DYSBALANCE
0123
Abscesses
Aggressive
Airways
Anxious
Aortic thrombosis
Borreliosis
Claws
Constipation
Diarrhea
Disinterested
Ears
Eyes
Flatulence
Fur
Genital apparatus
Gums
Heart
Hyperactive
Irritable colon
Kidneys
Liver
Locomotor system
Metabolism
Poisoning
Psychological/behavioral problems
Seizures
Skin
Teeth
Urinary incontinence
Worms
MEDICATION
YESNO
Mao inhibitor
Painkillers
Cortisone
Cardiovascular medication
Neuroleptics
Hormones
Antibiotics
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