Javascript must be enabled for the correct page display
Mon, Tues, Wed, Fri: 8:00am – 5:00pm
Thurs: 8:00am – 6:30pm
Open Saturday Nov. 7th & 21st: 9am - 12pm
After Hours Emergencies
(603) 287-1181
(603) 369-4446
[email protected]
Select Language
English
French
Spanish
Phone
Hours
Follow us
Contact Us
(603) 287-1181
Working Hours
Mon, Tues, Wed, Fri
8:00am – 5:00pm
Thurs
8:00am – 6:30pm
Sat
9am - 12pm
Follow Us
Facebook
Instagram
Google
Menu
Search
Main Menu
Services
Toggle Dropdown
Cats
Toggle Dropdown
Cat Acupuncture
Cat Anesthesia
Cat Dentistry
Cat Labwork
Cat Nutrition
Cat Senior Care
Cat Spay and Neuter
Cat Urinary Problems
Cat Wellness Exams
Kitten Care
Dogs
Toggle Dropdown
Brachycephalic Dogs
Dog Acupuncture
Dog Anesthesia
Dog Dentistry
Dog Fleas and Ticks
Dog Lab Work
Dog Nutrition
Dog Spaying and Neutering
Dog Urinary Problems
Dog Wellness Exam
Puppy Care
General
Toggle Dropdown
Acupuncture
Compassionate End of Life Care
Diagnostics
Emergency Vet Care
Laser Therapy
Microchipping
Pet Dental Care
Veterinary Surgery
Wellness Care
About Us
Toggle Dropdown
Meet the Team
Toggle Dropdown
Veterinarians
Client Service Representatives
Veterinary Technicians
Veterinary Assistants
Careers
Toggle Dropdown
Client Service Representative
Now Hiring - Veterinary Assistant
Now Hiring - Veterinary Technician
Now Hiring - Associate Veterinarian
Externships Opportunities in Grantham, NH
In The News
Our History
AAHA Accredited
Hospital Tour
Community Involvment
Pet Success Stories
Forms
Resources
Toggle Dropdown
Blog
Toggle Dropdown
Cats
Dogs
Other
Breeds
Toggle Dropdown
Dogs
Cats
Helpful Links
New Clients
Online Pharmacy
Payment Options
Pet Friendly Guide to Grantham
New to Grantham, NH? Your Pet Needs a Veterinarian, Too.
Online Pharmacy
Request an Appointment
Search
Online Pharmacy
Request an Appointment
Online Pharmacy
Request an Appointment
Menu
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
Not Vomiting
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.
Not Vomiting
When does vomiting occur?
*
After eating
On an empty stomach
Random
Not Vomiting
Diarrhea Details
Is your pet having diarrhea
*
Yes
No
Frequency
*
Slightly loose stool
Frequent loose stool
Very frequent / urgent
No Diarrhea
Stool appearance (check all that apply)
*
Soft
Watery
Mucus present
Blood (bright red)
Black/tarry
Firm
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
None
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
None that aware of
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.
50 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
*
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
