Skip to content
585-346-6021
Join Us
Home
Forms
Vomiting
Pages
About us
Home
Forms
Vomiting
Pages
About us
Vomiting
Vomiting
HISTORY OF PRESENTING ILLNESS
Duration
Are you able to keep any fluids or food down?
*
Yes
No
Onset and progression
Sudden onset
Insidious onset / Chronic
Persistent vomiting
Intermittent vomiting
Type of vomiting
Acid eructation (Burping)
Oesophageal regurgitation
Projectile vomiting
Vomitus - content
Undigested food
Coffee ground vomitus
Blood
Bile
Vomitus - Smell
Sour smell
Faecal smell
When does it occur?
Early morning vomiting
Preceded by headache
Progressive/persistent vomiting
After emotional or psychological disturbances
Following exposure to unpleasant smell
Following exposure to unpleasant sight
Following exposure to unpleasant taste
Relation to Meals
Unrelated to meals
Occurs on an empty stomach
Soon after food & occurring regularly
Occurring one hour after meals
Occurring 4 to 6 hours after meals
Is the patient pregnant? (For Female patient)
Yes
No
Not sure
Missed periods
History of:
Recurrent projectile vomiting following Headache
Photophobia
exposure to anyone with similar symptoms
addiction to alcohol
Intake of poison
Associated symptoms
Nausea
Abdominal pain
Diarrhoea
Relief of abdominal pain after vomiting
Chest pain
Sweating
Shortness of breath
Confusion
Feeling full/early satiety
Dizziness (Light-headedness)
Recent unexplained weight loss
Fits/Seizures
tinnitus
Vertigo
Fever
Hydration status
Thirst
Infrequent urination
Dry mouth
Weakness
PAST HISTORY
Past medical and surgical history
Head injury
Temporal lobe seizure
Vagotomy
Hysterical episodes
Psychiatric illnesses
Drug History
Checkboxes
Digoxin
Oral contraceptives
Analgesics
Chemotherapy
Radiotherapy
FAMILY HISTORY
Family history
Migraine
Psychiatric illness
Submit
If you are human, leave this field blank.
