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Chiari/COMS Project Questionnaire




Please fill out a separate questionnaire for each dog that is being brought in for screening.
Microchip *
Is your dog having clinical signs? *
If yes, check all that apply:
Has your dog had a previous MRI or CT scan? *
Has your dog had any previous surgery? *
Has your dog had any previous injuries? *
Has your dog been diagnosed with a heart murmur? *
Has your dog ever had a seizure? *
Has your dog been diagnosed with any other clinical diseases? *
Have any of your dog's siblings been diagnosed with a particular condition? *