Canine/Feline Gastroenteritis History Questionnaire Name First Last Date MM slash DD slash YYYY Current Diet (include treats and table foods/extras):Any new foods or diet changes in the past 2 months?YesNoExplain if neededCurrent Medications and Supplements:Any possible ingestion of non-food objects? (toys, mulch/sticks, string, etc.)YesNoAppetite decreased?YesNoDiarrhea/soft stools/increasedYesNoDate signs started MM slash DD slash YYYY Increased frequency?YesNoIncreased volume of stool?YesNoBlood?YesNoColor change?YesNoMucus?YesNoExposure to areas other dogs outside the home defecate/kennels/day camp?YesNoVomiting/regurgitation/spitting up?YesNoIncreased interest in eating grass?YesNoDate signs started MM slash DD slash YYYY Frequency of vomiting?Is there a trigger for vomiting or a typical time vomiting is seen?Can patient keep food down?YesNoSometimesCan patient keep water down?YesNoSometimesEnter the code below
