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Vomiting & Diarrhea Intake Form (Dog & Cat)
Client Name
First
Last
Email
Phone Number
Please enter a valid phone number.
Pet Name
Species
- Select -
Dog
Cat
Breed
Age
Sex
- Select -
Male
Male Neutered
Female
Female Spayed
Weight
Primary Concern
What symptoms is your pet experiencing? (check all that apply)
Vomiting
Diarrhea
Both vomiting & diarrhea
Loss of appetite
Lethargy
Abdominal pain
Other…
Enter other…
When did the symptoms start?
Are symptoms
Getting better
Getting worse
Staying the same
Vomiting Details
Is your pet vomiting?
Yes
No
Frequency
Once
Occasionally
Multiple times per day
What does the vomit look like? (check all that apply
Food
Yellow bile
White foam
Clear liquid
Blood (red)
Dark/coffee ground appearance
Foreign material (toys, fabric, etc.)
Retching but nothing comes up.
When does vomiting occur?
After eating
On an empty stomach
Random
Diarrhea Details
Is your pet having diarrhea
Yes
No
Frequency
Slightly loose stool
Frequent loose stool
Very frequent / urgent
Stool appearance (check all that apply)
Soft
Watery
Mucus present
Blood (bright red)
Black/tarry
Any straining?
Yes
No
Any accidents in the house?
Yes
No
Appetite & Water Intake
Appetite
Normal
Decreased
Not eating
Water intake
Normal
Decreased
Increased
Behavior Changes
Energy level
Normal
Slightly decreased
Very lethargic
Any signs of discomfort?
Whining
Restlessness
Hunched posture
Sensitivity when touched
Possible Causes / Exposure
Has your pet had access to any of the following? (check all that apply)
Trash
New treats/food
Table scraps
Bones/rawhide
Toys/foreign objects
Toxins (plants, chemicals, medications)
Other animals’ feces
Any recent changes in diet?
Yes
No
Any recent stress or changes in environment?
Yes
No
Preventative Care
Is your pet current on vaccines?
Yes
No
Not Sure
Is your pet on parasite prevention?
Yes
No
List what heartworm/flea/tick control products your pet is current on and the last date given
Last deworming (if known)
Medical History
Any previous episodes like this?
Yes
No
Any known medical conditions?
Current medications/supplements
Optional (Helpful for Diagnosis)
Please attach photos of vomit or stool if submitting digitally.
One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
Additional Notes or Concerns
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