ARLINGTON CAT CLINIC – VOMITING HISTORY FORM

1
What day and time is your appointment?
Date
Month
Day
Year
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
2
What day and time is your appointment?* This field is required.
Appointment Date
Appointment Time
3
Owner's Name
Last Name
Patient Name
4
Email
When did your cat begin vomiting?
How frequent does your cat vomit?
Better
Worse
No Change
Is the vomiting getting
Outside your yard?
Indoor
Outdoor
Indoor/Outdoor
5
Does your cat have access to garbage cans,either within your house or outside your yard?
Does your cat have toys that it plays with that could have been swallowed?
Does your cat have access to sewing materials,such as thread or needles, rubber bands, or strings?
Do you have other pets living in your home?
Are any of them vomiting?
6
Is your cat still eating?
More
Less
No change
How much?
If no, how long has it been since your cat ate?
7
When does your cat vomit in relation to eating?
unknown
immediately
5-15 minutes later
15-30 minutes later
30-60 minutes later
1-2 hours later
2-5 hours later
more than 5 hours later
8
What does the vomit look like?
Pile of undigested food
Tube of undigested food
Partially digested food
Contains bright blood
White foam
Yellow liquid
Watery
Please Select
If other, please describe
9
Does your cat do any retching, heaving, or makenoise before vomiting?
Is vomiting more frequent with certain diets or flavors of food?
Is your cat currently on any medication for vomiting?
Has it helped?
Increased
Decreased
The same
Is your cat's water consumption
10
I am in this vehicle
( Please list model and color )
11
Best phone number for today's appointment
( The veterinarian and technician will use this number to communicate with you through the appointment. )
12
Primary reason for Appointment / Concern ( Please be as detailed as possible. )
Huge
Large
Normal
Small
Ok
Ok
13
List Medications your pet is currently taking
Huge
Large
Normal
Small
Ok
Ok
14
Do you need refills of any of these Medications?
YESNO
15
Do you need refills on any prescription pet food?
YESNO
Should be Empty: