Vomiting and Diarrhea Questionnaire – Rice Village Animal Hospital

Name *

First

Last

E-mail *

My pet has

vomiting
diarrhea
both

When did it start?

today
yesterday
two or more days ago

How frequent is the vomiting?

What is your pet’s normal diet?

Did your pet eat anything other than its normal diet recently?

yes
no

If yes, what/when?

Does vomiting occur only after eating?

yes
no

Does your pet vomit

Has your pet been treated for vomiting before?

yes
no

If yes, when/where?

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

If yes, when/where?

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

If yes, what/when

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

If yes, what

Is your pet on any medications?

yes
no

If yes, which medications

Does your pet have any other symptoms not addressed on this form?

yes
no

If yes, please describe