Vomiting and Diarrhea History Form
Patient/Owner Information
Patient name
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Date
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Month
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Day
Year
Date
Owner name
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What diet is your pet currently on?
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Has the diet changed recently?
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How is your pet’s appetite? (Not Eating, Decreased, Normal, Increased)
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How is your pet’s water intake? (Increased, Normal, Decreased)
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How is your pet’s activity? (Normal or Decreased)
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How is your pet’s demeanor? (Normal, Lethargic/Depressed, Anxious, Etc.)
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Does your pet tend to chew on things such as toys, clothes, string, hair ties, robes, raw hides, etc.?
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Does your pet get human food, table scraps, bones or treats?
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Yes
No
Please describe
Any exposure to toxins (rat poison, antifreeze, chocolate, grapes, etc.), plants, human medication, recreational drugs, etc.?
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Yes
No
Please describe
Has your pet gotten into the garbage?
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Yes
No
If yes, what was in the garbage (bathroom or kitchen trash, etc.)?
Is your pet having vomiting, diarrhea or both?
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When did the symptoms start?
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What is the frequency and how many times has your pet had vomiting/diarrhea?
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What is the most recent vomit/diarrhea?
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Please Describe
If your pet is vomiting, is there retching or effort before/during the vomiting or is the vomit/fluid coming up without effort?
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If your pet is vomiting, what does the vomit consist of (clear foam, bile – yellow liquid, blood, digested or undigested food, hair, foreign body, other)?
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If your pet is vomiting, is your pet keeping down any food and/or water?
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If your pet is vomiting, how soon after eating does the vomiting occur?
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If your pet is vomiting, does your pet seem to feel better after vomiting?
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If Your Pet is Having Diarrhea, Describe the Stools (Normal, Soft, Liquid, Mucus, Blood, Pale, or Dark/Black)
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If your pet is having diarrhea, are they having accidents in the house or asking to go out more frequently?
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Has there been anything new or stressful (recently kenneled/boarded, home remodel, recent travel, new people or pets to the household)?
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Does your pet have any known food allergies?
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Have you given any medications for vomiting and diarrhea?
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Yes
No
If so, please list the name, dosage and frequency
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Does your pet have frequent or intermittent vomiting and/or diarrhea?
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Yes
No
If So, Please Describe (Frequency, Amount, Consistency)
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Has your pet been exposed to other animals (besides those in your own household) in the past 2 weeks?
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Yes
No
If so, please describe
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Submit
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