{"id":527245,"date":"2025-11-21T11:34:25","date_gmt":"2025-11-21T11:34:25","guid":{"rendered":"https:\/\/veteo.eu\/?page_id=527245"},"modified":"2026-04-29T11:45:30","modified_gmt":"2026-04-29T11:45:30","slug":"questionnaire","status":"publish","type":"page","link":"https:\/\/veteo.eu\/en\/services\/cytometry\/questionnaire\/","title":{"rendered":"Cytometry \u2013 Examination questionnaire"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row bg_type=&#8221;bg_color&#8221; bg_override=&#8221;full&#8221; bg_color_value=&#8221;#D31313&#8243;][vc_column][vc_column_text css=&#8221;&#8221;]<\/p>\n<h3><span style=\"color: #ffffff;\">Please include the patient\u2019s current cytological test results and\/or fresh cytological preparations related to the material submitted for flow cytometric analysis.<\/span><\/h3>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f527244-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"527244\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/527245#wpcf7-f527244-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"527244\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f527244-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:527244,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;material-do-badania-inny-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;material-do-badania&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;other&quot;}]},{&quot;then_field&quot;:&quot;objawy-ogolne-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;objawy-ogolne&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;other&quot;}]},{&quot;then_field&quot;:&quot;wezly-chlonne-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;wezly-chlonne&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;yes&quot;}]},{&quot;then_field&quot;:&quot;wezly-chlonne2-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;rodzaj-wezlow&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;other&quot;}]},{&quot;then_field&quot;:&quot;choroby-zakazne-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;choroby-zakazne&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;yes&quot;}]},{&quot;then_field&quot;:&quot;choroby-zakazne2-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;rodzaj-choroby-zakaznej&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;other&quot;}]},{&quot;then_field&quot;:&quot;szczepienia-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;szczepienia&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;yes&quot;}]},{&quot;then_field&quot;:&quot;leki-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;leki&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;yes&quot;}]},{&quot;then_field&quot;:&quot;badania-obrazowe-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;badania-obrazowe&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;yes&quot;},{&quot;if_field&quot;:&quot;objawy-ogolne&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;zmiany sk\\u00f3rne&quot;},{&quot;if_field&quot;:&quot;objawy-ogolne&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;biegunka&quot;},{&quot;if_field&quot;:&quot;gatunek&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;DOG&quot;},{&quot;if_field&quot;:&quot;gatunek&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Dog&quot;},{&quot;if_field&quot;:&quot;gatunek&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;dog&quot;},{&quot;if_field&quot;:&quot;gatunek&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;CAT&quot;},{&quot;if_field&quot;:&quot;gatunek&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Cat&quot;},{&quot;if_field&quot;:&quot;gatunek&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;cat&quot;}]},{&quot;then_field&quot;:&quot;wyniki-badan-laboratoryjnych-g&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;wyniki-badan-laboratoryjnych&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;other&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;notice_dismissed_rollback-cf7-6.0.2&quot;:true}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"kontener\">\n\t<div class=\"lewa\">\n\t\t<h2>Referring veterinarian\u2019s details\n\t\t<\/h2>\n\t\t<p><label>Name of the facility* <span class=\"wpcf7-form-control-wrap\" data-name=\"nazwa-placowki\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nazwa-placowki\" \/><\/span><\/label>\n\t\t<\/p>\n\t\t<p><label>Name of the veterinarian* <span class=\"wpcf7-form-control-wrap\" data-name=\"lekarz\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"lekarz\" \/><\/span><\/label>\n\t\t<\/p>\n\t\t<p><label>Phone number* <span class=\"wpcf7-form-control-wrap\" data-name=\"telefon\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefon\" \/><\/span><\/label>\n\t\t<\/p>\n\t\t<p><label>Email address* <span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span><\/label>\n\t\t<\/p>\n\t\t<p><label>Date of sample collection* <span class=\"wpcf7-form-control-wrap\" data-name=\"data-pobrania\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" min=\"2019-12-01\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-pobrania\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"prawa\">\n\t\t<h2>Basic information\n\t\t<\/h2>\n\t\t<p><label>Owner\u2019s name* <span class=\"wpcf7-form-control-wrap\" data-name=\"nazwisko-wlasciciela\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nazwisko-wlasciciela\" \/><\/span><\/label>\n\t\t<\/p>\n\t\t<p><label>Patient\u2019s name* <span class=\"wpcf7-form-control-wrap\" data-name=\"imie-pacjenta\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"imie-pacjenta\" \/><\/span><\/label>\n\t\t<\/p>\n\t\t<p><label>Species* <span class=\"wpcf7-form-control-wrap\" data-name=\"gatunek\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"gatunek\"><option value=\"dog\">dog<\/option><option value=\"cat\">cat<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t\t<div class=\"lewa\">\n\t\t\t<p><label>Age* <span class=\"wpcf7-form-control-wrap\" data-name=\"wiek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required wiekk\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"wiek\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"prawa\">\n\t\t\t<p><label>Breed* <span class=\"wpcf7-form-control-wrap\" data-name=\"rasa\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required rasaa\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rasa\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"lewa\">\n\t\t\t<p><label>Sex* <span class=\"wpcf7-form-control-wrap\" data-name=\"plec\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"plec\"><option value=\"male\">male<\/option><option value=\"female\">female<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><label>Material for examination* <span class=\"wpcf7-form-control-wrap\" data-name=\"material-do-badania\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"material-do-badania\"><option value=\"lymph node biopsy in transport medium (with cytology slide)\">lymph node biopsy in transport medium (with cytology slide)<\/option><option value=\"peripheral blood in EDTA (with a fresh blood smear)\">peripheral blood in EDTA (with a fresh blood smear)<\/option><option value=\"bone marrow biopsy (with cytology slide)\">bone marrow biopsy (with cytology slide)<\/option><option value=\"body cavity fluid (with cytology slide)\">body cavity fluid (with cytology slide)<\/option><option value=\"other\">other<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t\t<div data-id=\"material-do-badania-inny-g\" data-orig_data_id=\"material-do-badania-inny-g\"  data-class=\"wpcf7cf_group\">\n\t\t\t<p><label>What other material? <span class=\"wpcf7-form-control-wrap\" data-name=\"material-do-badania-inny\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"material-do-badania-inny\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<h2>Clinical suspicion \/ cytological diagnosis*\n<\/h2>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"podejrzenia-kliniczne\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"podejrzenia-kliniczne\" \/><\/span><\/label>\n<\/p>\n<h2>General symptoms*\n<\/h2>\n<p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"objawy-ogolne\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"objawy-ogolne[]\" value=\"fever\" \/><span class=\"wpcf7-list-item-label\">fever<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"objawy-ogolne[]\" value=\"weakness\" \/><span class=\"wpcf7-list-item-label\">weakness<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"objawy-ogolne[]\" value=\"weight loss \/ cachexia\" \/><span class=\"wpcf7-list-item-label\">weight loss \/ cachexia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"objawy-ogolne[]\" value=\"pale mucous membranes\" \/><span class=\"wpcf7-list-item-label\">pale mucous membranes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"objawy-ogolne[]\" value=\"petechiae\" \/><span class=\"wpcf7-list-item-label\">petechiae<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"objawy-ogolne[]\" value=\"none\" \/><span class=\"wpcf7-list-item-label\">none<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"objawy-ogolne[]\" value=\"other\" \/><span class=\"wpcf7-list-item-label\">other<\/span><\/span><\/span><\/span><\/label>\n<\/p>\n<div data-id=\"objawy-ogolne-g\" data-orig_data_id=\"objawy-ogolne-g\"  data-class=\"wpcf7cf_group\">\n\t<p><label>Describe other symptoms* <span class=\"wpcf7-form-control-wrap\" data-name=\"inne-objawy\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"inne-objawy\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<p><label>Duration of symptoms* <span class=\"wpcf7-form-control-wrap\" data-name=\"czas-trwania\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"czas-trwania\" \/><\/span><\/label>\n<\/p>\n<h2>Laboratory test results*\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wyniki-badan-laboratoryjnych\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"lymphocytosis\" \/><span class=\"wpcf7-list-item-label\">lymphocytosis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"monocytosis\" \/><span class=\"wpcf7-list-item-label\">monocytosis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"presence of atypical cells in peripheral blood\" \/><span class=\"wpcf7-list-item-label\">presence of atypical cells in peripheral blood<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"erythropenia\" \/><span class=\"wpcf7-list-item-label\">erythropenia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"neutropenia\" \/><span class=\"wpcf7-list-item-label\">neutropenia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"thrombocytopenia\" \/><span class=\"wpcf7-list-item-label\">thrombocytopenia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"hyperglobulinemia\" \/><span class=\"wpcf7-list-item-label\">hyperglobulinemia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"hypercalcemia\" \/><span class=\"wpcf7-list-item-label\">hypercalcemia<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"none\" \/><span class=\"wpcf7-list-item-label\">none<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"wyniki-badan-laboratoryjnych[]\" value=\"other\" \/><span class=\"wpcf7-list-item-label\">other<\/span><\/span><\/span><\/span>\n<\/p>\n<div data-id=\"wyniki-badan-laboratoryjnych-g\" data-orig_data_id=\"wyniki-badan-laboratoryjnych-g\"  data-class=\"wpcf7cf_group\">\n\t<p><label>Which other results? <span class=\"wpcf7-form-control-wrap\" data-name=\"wyniki-badan-laboratoryjnych-inny\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"wyniki-badan-laboratoryjnych-inny\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<h2>Lymph node enlargement*\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wezly-chlonne\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"wezly-chlonne\" value=\"no\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"wezly-chlonne\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><\/span><\/span>\n<\/p>\n<div data-id=\"wezly-chlonne-g\" data-orig_data_id=\"wezly-chlonne-g\"  data-class=\"wpcf7cf_group\">\n\t<p><label>Indicate the enlarged lymph nodes:* <span class=\"wpcf7-form-control-wrap\" data-name=\"rodzaj-wezlow\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"rodzaj-wezlow[]\" value=\"popliteal\" \/><span class=\"wpcf7-list-item-label\">popliteal<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rodzaj-wezlow[]\" value=\"mandibular\" \/><span class=\"wpcf7-list-item-label\">mandibular<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rodzaj-wezlow[]\" value=\"prescapular\" \/><span class=\"wpcf7-list-item-label\">prescapular<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rodzaj-wezlow[]\" value=\"mesenteric\" \/><span class=\"wpcf7-list-item-label\">mesenteric<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rodzaj-wezlow[]\" value=\"mediastinal\" \/><span class=\"wpcf7-list-item-label\">mediastinal<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rodzaj-wezlow[]\" value=\"generalized lymphadenopathy\" \/><span class=\"wpcf7-list-item-label\">generalized lymphadenopathy<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"rodzaj-wezlow[]\" value=\"other\" \/><span class=\"wpcf7-list-item-label\">other<\/span><\/span><\/span><\/span><\/label>\n\t<\/p>\n\t<div data-id=\"wezly-chlonne2-g\" data-orig_data_id=\"wezly-chlonne2-g\"  data-class=\"wpcf7cf_group\">\n\t\t<p><label>Describe* <span class=\"wpcf7-form-control-wrap\" data-name=\"inne-wezly\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"inne-wezly\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<h2>Hepatomegaly*\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"powiekszenie-watroby\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"powiekszenie-watroby\" value=\"not examined\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">not examined<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"powiekszenie-watroby\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"powiekszenie-watroby\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><\/span><\/span>\n<\/p>\n<h2>Splenomegaly*\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"powiekszenie-sledziony\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"powiekszenie-sledziony\" value=\"not examined\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">not examined<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"powiekszenie-sledziony\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"powiekszenie-sledziony\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><\/span><\/span>\n<\/p>\n<h2>Findings on imaging (X-ray \/ ultrasound \/ MRI)*\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"badania-obrazowe\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"badania-obrazowe\" value=\"not examined\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">not examined<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"badania-obrazowe\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"badania-obrazowe\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><\/span><\/span>\n<\/p>\n<div data-id=\"badania-obrazowe-g\" data-orig_data_id=\"badania-obrazowe-g\"  data-class=\"wpcf7cf_group\">\n\t<p><label>Which ones?* <span class=\"wpcf7-form-control-wrap\" data-name=\"jakie-badania-obrazowe\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"jakie-badania-obrazowe\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<h2>Suspected or past infectious\/vector-borne diseases*\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"choroby-zakazne\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"choroby-zakazne\" value=\"no\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"choroby-zakazne\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><\/span><\/span>\n<\/p>\n<div data-id=\"choroby-zakazne-g\" data-orig_data_id=\"choroby-zakazne-g\"  data-class=\"wpcf7cf_group\">\n\t<p><label>Which ones?* <span class=\"wpcf7-form-control-wrap\" data-name=\"rodzaj-choroby-zakaznej\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"rodzaj-choroby-zakaznej[]\" value=\"Ehrlichiosis\" \/><span class=\"wpcf7-list-item-label\">Ehrlichiosis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rodzaj-choroby-zakaznej[]\" value=\"Lyme disease\" \/><span class=\"wpcf7-list-item-label\">Lyme disease<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"rodzaj-choroby-zakaznej[]\" value=\"other\" \/><span class=\"wpcf7-list-item-label\">other<\/span><\/span><\/span><\/span><\/label>\n\t<\/p>\n\t<div data-id=\"choroby-zakazne2-g\" data-orig_data_id=\"choroby-zakazne2-g\"  data-class=\"wpcf7cf_group\">\n\t\t<p><label>Describe* <span class=\"wpcf7-form-control-wrap\" data-name=\"inne-choroby-zakazne\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"inne-choroby-zakazne\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<h2>Treatment administered\n<\/h2>\n<p><label>Medications* <span class=\"wpcf7-form-control-wrap\" data-name=\"leki\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"leki\" value=\"no\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"leki\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><\/span><\/span><\/label>\n<\/p>\n<div data-id=\"leki-g\" data-orig_data_id=\"leki-g\"  data-class=\"wpcf7cf_group\">\n\t<p><label>Which ones \/ date of last dose?* <span class=\"wpcf7-form-control-wrap\" data-name=\"jakie-leki\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"jakie-leki\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<p><label>Vaccinations within the last 2 weeks?* <span class=\"wpcf7-form-control-wrap\" data-name=\"szczepienia\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"szczepienia\" value=\"no\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"szczepienia\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><\/span><\/span><\/label>\n<\/p>\n<div data-id=\"szczepienia-g\" data-orig_data_id=\"szczepienia-g\"  data-class=\"wpcf7cf_group\">\n\t<p><label>Which ones?* <span class=\"wpcf7-form-control-wrap\" data-name=\"jakie-szczepienia\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"jakie-szczepienia\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<h2>Current test results to attach:\n<\/h2>\n<p><label>Attach files<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"plik\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.png,.pdf,.gif,.jpeg\" aria-invalid=\"false\" type=\"file\" name=\"plik\" \/><\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"plik2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.png,.pdf,.gif,.jpeg\" aria-invalid=\"false\" type=\"file\" name=\"plik2\" \/><\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"plik3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.png,.pdf,.gif,.jpeg\" aria-invalid=\"false\" type=\"file\" name=\"plik3\" \/><\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"plik4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.png,.pdf,.gif,.jpeg\" aria-invalid=\"false\" type=\"file\" name=\"plik4\" \/><\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"plik5\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.png,.pdf,.gif,.jpeg\" aria-invalid=\"false\" type=\"file\" name=\"plik5\" \/><\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"plik6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.png,.pdf,.gif,.jpeg\" aria-invalid=\"false\" type=\"file\" name=\"plik6\" \/><\/span><\/label>\n<\/p>\n<h2>Additional information\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"jakie-dodatkowe-informacje3\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"jakie-dodatkowe-informacje3\"><\/textarea><\/span><br \/>\n<\/>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row 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