ALICAM Patient Info Form

Patient Information Form
Veterinarian and Hospital Information
Veterinarian Name *

First Name Last Name
Email where report will be sent *
The report will be sent to this email address
Clinic Name *

Clinic Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Clinic Phone Number *
Patient Information
Patient Name *
Client Last Name *
Patient ID
Your clinic's ID for this patient
Breed *
If other, write in breed *
Age (years/months) *
Weight (kg) *
Sex *
Capsule Serial Number *
ex: G1234.9876 or A006BV.539
Date Capsule Administered *

Month Day Year Date Picker Icon
Date Capsule Retrieved

Month Day Year Date Picker Icon
Duration patient was fasted (hours) *
Clinical History
Brief summary of the progression of clinical signs and reason for ALICAM *
Duration of clinical signs *
Clinical signs (check all that apply) *

Vomiting Regurgitation Hematemesis Anorexia Weight loss Lethargy Tenesmus Flatulence Diarrhea Melena Hematochezia
Characterize the stools (check all that apply) *

Small bowel diarrhea Large bowel diarrhea Mixed bowel diarrhea
Does this patient have vomiting or regurgitation? (check all that apply)

No Vomiting Regurgitation Hematemesis
Appetite *
Does this patient have weight loss? *
Body Condition Score (9-point scale) *
Current Diet *

Hill's i/d Hill's w/d Hill's z/d Hill's z/d ultra Iams Intestinal Plus (Low Residue) Purina EN Royal Canin Low Fat Royal Canin Novel Protein Royal Canin HP Nonprescription Novel Protein Nonprescription Maintenance Homemade Raw
Diagnostic Test Results
Radiographs taken *

Yes No
Radiograph results *
Ultrasound performed *

Yes No
Ultrasound results *
Ultrasonographer *

Radiologist (ACVR or ECVDI) Internist Criticalist Cardiologist General Practitioner Technician
CBC, chemistry panel, UA abnormalities *
Fecal tests *
Other tests (ie PLI, TLI, Cobalamin, Folate) *
Imaging Findings
Current Treatment
Prokinetics *

Yes No
Prokinetic *

Metoclopramide Cisapride Erythromycin
Corticosteroids

Prednisone Prednisolone Dexamethasone Budesonide
Corticosteroid Dose/Frequency (mg/kg)
Antibiotics

Metronidazole Tylosin Enrofloxacin Amoxicillin
Antibiotic Dose/Frequency (mg/kg)
Gastroprotectants

Omeprazole Pantoprazole Famotidine Sucralfate Misoprostol
Gastroprotectant Dose/Frequency (mg/kg)
Antiemetics

Maropitant (Cerenia) Metoclopramide Ondansetron/Dolasetron
Antiemetic Dose/Frequency (mg/kg)
Other Medications
Was there a response to these medications?
Additional Medical History
Other Non-GI Diseases
Additional Pertinent Information
Upload medical records, labs, or previous imaging reports
Additional Files
Additional Files
Should be Empty:

Veterinarian and Hospital Information

Patient Information

Clinical History

Diagnostic Test Results

Current Treatment

Additional Medical History