If your child has repeated bouts of vomiting, please collect the following information on three episodes of vomiting before you make an initial or follow-up appointment. This information may be very helpful to your physician in reaching a correct diagnosis.

Time and Place

Date:

Time of day:

Place (home, school, etc.):

People present:

Description of Vomiting

How much (ounces)?

Food or mucus?

For how long (minutes)?

What did it keep your child from doing?

Triggers for Vomiting

Thoughts or stresses before the vomiting (within 1 hour):

Feelings (for example, upset or afraid) before the vomiting (within 1 hour):

Activities before the vomiting (within 2 hours):

Food eaten before the vomiting (within 4 hours):

Treatment

What did you do to help your child feel better?

Your Observation

What do you think caused the vomiting this time?