Yes No

Does your baby experience diarrhea an average of two to four times a day for more than five to seven days?

Yes No

Does your baby have blood in the stool?

Yes No

Does your baby experience vomiting, aside from normal mealtime “spit-up”?

Yes No

Does your baby have reflux symptoms or experience difficulty swallowing?

Yes No

Does your baby have a skin rash?

Yes No

Does your baby cry continuously and inconsolably for long periods of time?

Yes No

Is your baby not following normal growth patterns, according to standard developmental growth charts?

Yes No

Does your baby wheeze, struggle to breathe or have excess mucus in the nose and throat?

Yes No

Does your baby suffer from dehydration, loss of appetite or lack of energy?

Yes No

Does your baby experience gassiness with any of the above symptoms?

Your Child's Name:

Your Child's Date of Birth:

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