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Vomiting and Diarrhea Questionnaire
First Name
Last Name
E-mail
My pet has
vomiting
diarrhea
both
When did it start?
today
yesterday
two or more days ago
How frequent is the vomiting?
more than once per hour
hourly
daily
weekly
occasionally
What is your pet’s normal diet?
Did your pet eat anything other than its normal diet recently?
Yes
No
Does vomiting occur only after eating?
Yes
No
Does your pet vomit
undigested food
partially digested food
foam
yellow liquid
hair
Has your pet been treated for vomiting before?
Yes
No
Does your pet’s diarrhea occur
several times daily
daily
occasionally
Is the stool
watery
cow patty like
normal until the end
mucousy
Have you noticed any blood in the stool?
Yes
No
Has your pet been treated for diarrhea before?
Yes
No
Has your pet been boarded or out around other pets recently?
Yes
No
Could your pet have been exposed to any toxins or swallowed anything?
Yes
No
Have there been any changes in your pet’s environment recently (new family member, move, loss of a family member, etc.)?
Yes
No
Have there been any other changes in your pet (increased or decreased appetite, increased or decreased consumption or water, lethargy or hyperactivity, etc.)?
Yes
No
Is your pet on any medications?
Yes
No
Does your pet have any other symptoms not addressed on this form?
Yes
No