Cyclic Vomiting Syndrome Episode Diary | |||||||||||
| Date | |||||||||||
| Time Episode Began | |||||||||||
| Time Episode Ended | |||||||||||
| Warning Signs (aura) | |||||||||||
| Location of Pain (if any) | |||||||||||
| Type of Pain (pressing, throbbing, piercing, etc.) | |||||||||||
| Intensity of Pain (10 most intense) |
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| Intensity of Nausea/Vomiting (10 most intense) |
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| Other Symptoms | |||||||||||
| Medication Taken/ Other Treatment | |||||||||||
| Effect of Treatment | |||||||||||
| How Episode Affected My Normal Routine | |||||||||||
| Hours of Sleep the Night Before the Episode | |||||||||||
| What I Ate Before the Episode (caffeine, diet soda, chocolate, hot dogs, food with artificial sweeteners, processed foods) | |||||||||||
| Activities Before Episode Occurred | |||||||||||
| Important or Stressful Events That Occurred Today | |||||||||||
| Comments | |||||||||||