Please complete this form to request medical assistance for each sick C.A.T.S. foster animal:

Foster's First Name*

Foster's Last Name*

Email*

Phone Number* (cell preferred)

Can you send/receive text messages at this number?*
Yes
No

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Dog/Cat's Name*

Male or Female*
Male
Female
Can't Tell

Dog/Cat's Age*

Dog/Cat's Weight*

Dog/Cat's Description* (color, pattern, breed)

Is this animal sharing food/water bowls with any other animals?
Yes
No

If a cat, is it sharing a litterbox with any other cat(s)?
Yes
No

Have you given any medication to date?
Yes
No

If yes, what, how much & when did you start?

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FIRMNESS: On a scale of 1 to 5 where 1 is completely liquid and 5 is normal/firm, where does your foster rate?

COLOR: On a scale of 1 to 5 where 1 is yellow and 5 is normal/brown, where does your foster rate?

SMELL: On a scale of 1 to 5 where 1 is "evacuate the house" and 5 is normal poop smell, where does your foster rate?

BLOOD:
Any blood in the stool?
Yes
No

If yes, how much?
Slight
Marbled throughout
Puddle of blood

WORMS:
Any sign of worms?
Yes
No

What is the date that the diarrhea began?

CHANGES IN DIET:
Have you changed his/her diet? (start from 2 weeks before symptoms through now)
Yes
No

What is the date that you changed the diet?

What EXACTLY were the changes in diet?

CHANGES IN ENVIRONMENT:
Has your foster been recently exposed to a new animal or a new enviromnent? Yes
No

Any new "stresses" in your foster's life? If yes, what EXACTLY

OTHER:
Please note any other symptoms that you have noticed with this foster animal

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