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AZA CONTRACEPTIVE PATHOLOGY SURVEY

If no information is available please indicate so in the spaces provided 

Submitting veterinarian___________________________________________________________ 

Institution:______________________________________________________________________ 

Address:_____________________________________ Phone#  (________)_________________ 

       ___________________________ contact e-mail (opt) ___________________________ 

Species:_______________________________ ISIS:____________________ Sex:        M        F SB#______________ZOOID:__________________  Name:________________________________

Date of birth____________________        Date when tract was obtained:_____________________

Was it necropsy or surgery?_____________                      Weight (kg):_____________________

According to the animal’s record:

      Has this animal been cycling?     Y         N

      Has this animal been bred?   Y     N  Dates of pregnancies?___________________________

Has this animal spent its entire reproductive life at your zoo?        Y         N

If no, sites of previous residence____________________________________________________

      previous ID numbers (if known)________________________________________________

FOR MELENGESTROL (MGA) IMPLANTS:         Never been contracepted

Has this animal shown signs of estrus while implanted?      Y         N

Implant # Implant  Animal Date Date

      Weight Weight Inserted Removed

__________ __________ _________ ___________ ___________

__________ __________ _________ ___________ ___________

__________ __________ _________ ___________ ___________

__________ __________ _________ ___________ ___________ 

OTHER CONTRACEPTIVE If more space is needed please use the back

1) Type: __________________________________________Route: __________________________

Dose: __________________________________________Body weight: ____________________

Treatment dates: _____________________________________________________

2) Type: __________________________________________Route: __________________________

Dose: __________________________________________Body weight: ____________________

Treatment dates: _____________________________________________________

OTHER PROBLEMS THAT MAY AFFECT REPRODUCTION? (use the back if needed)

Please send tissues and form to:  Dr. Linda Munson / Dr. Anneke Moresco

Univ. of California, Dept VM-PMI,  4206 VM3A,  1 Shields Ave, Davis  CA 95616.

Questions:  Ph (530) 754-7963  lmunson@ucdavis.edu or amoresco@ucdavis.edu                   

Revised  May07 

Report of Adverse Reactions in Contracepted Animals 

Submitting veterinarian/Curator________________________________________________________ 

Institution:______________________________________________________________________ 

Species:_______________________________ ISIS:____________________ Sex:        M        F SB#______________ZOOID:__________________  Name:________________________________

Date of birth____________________ Weight (kg):_______________ 

Has this animal been cycling?     Y         N

Has this animal reproduced?   Y     N  Dates of pregnancies?______________________________

Has this animal shown signs of estrus while contracepted?      Y         N 

Drug: __________________________________________Route: __________________________

Dose: __________________________________________Body weight: ____________________

Treatment dates: _____________________________________________________

For MELENGESTROL (MGA) implants please include implant number.

Please use the back if more space is needed  

Mark all that apply and briefly explain: 

___ Mammary gland cancer  _______________________________________________________

___ Uterine cancer  _______________________________________________________

___ Pyometra  _______________________________________________________

___ Hydrometra/mucometra  _______________________________________________________

___ Fetal death _______________________________________________________

___ Endometrial hyperplasia  _______________________________________________________

___ Decidual reaction _______________________________________________________

___ Diabetes mellitus  _______________________________________________________

___ Skin disease   _______________________________________________________

___ Injection/Implant site reaction ______________________________________________________

___ Behavioral changes  _______________________________________________________

___ Weight changes  _______________________________________________________

___ Other  _______________________________________________________ 
 

Please send completed form to:  Dr. Linda Munson / Dr. Anneke Moresco

Univ. of California, Dept VM-PMI,  4206 VM3A,  1 Shields Ave, Davis  CA 95616.

Questions:  Ph (530) 754-7963  lmunson@ucdavis.edu

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