Ervets4pets.com - Vomiting and Diarrhea History Form

Patient name*

Date*

Date

Owner name*

What diet is your pet currently on?*

Has the diet changed recently?*

How is your pet’s appetite? (Not Eating, Decreased, Normal, Increased)*

How is your pet’s water intake? (Increased, Normal, Decreased)*

How is your pet’s activity? (Normal or Decreased)*

How is your pet’s demeanor? (Normal, Lethargic/Depressed, Anxious, Etc.)*

Does your pet tend to chew on things such as toys, clothes, string, hair ties, robes, raw hides, etc.?*

Does your pet get human food, table scraps, bones or treats?*

YesNo

Please describe

Any exposure to toxins (rat poison, antifreeze, chocolate, grapes, etc.), plants, human medication, recreational drugs, etc.?*

YesNo

Please describe

Has your pet gotten into the garbage?*

YesNo

If yes, what was in the garbage (bathroom or kitchen trash, etc.)?

Is your pet having vomiting, diarrhea or both?*

When did the symptoms start?*

What is the frequency and how many times has your pet had vomiting/diarrhea?*

What is the most recent vomit/diarrhea?*

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?*

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)?*

If your pet is vomiting, is your pet keeping down any food and/or water?*

If your pet is vomiting, how soon after eating does the vomiting occur?*

If your pet is vomiting, does your pet seem to feel better after vomiting?*

If Your Pet is Having Diarrhea, Describe the Stools (Normal, Soft, Liquid, Mucus, Blood, Pale, or Dark/Black)*

If your pet is having diarrhea, are they having accidents in the house or asking to go out more frequently?*

Has there been anything new or stressful (recently kenneled/boarded, home remodel, recent travel, new people or pets to the household)?*

Does your pet have any known food allergies?*

Have you given any medications for vomiting and diarrhea?*

YesNo

If so, please list the name, dosage and frequency*

Does your pet have frequent or intermittent vomiting and/or diarrhea?*

YesNo

If So, Please Describe (Frequency, Amount, Consistency)*

Has your pet been exposed to other animals (besides those in your own household) in the past 2 weeks?*

YesNo

If so, please describe*

Vomiting and Diarrhea History Form

Patient/Owner Information