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Diarrhea Questionnaire
First Name
Date
Last Name
Phone
Email
How long has the diarrhea/loose stool been present?
Is the diarrhea more severe now than a few days ago?
Consistency
- None -
Watery Stool
Stool is the thickness of pancake batter
Blood
- None -
Very bloody stool
Only sporadic blood present
Blood not present in stool
Bright red blood present
Dark, tarry blood present
Degree/Frequency
- None -
Entire stool is soft or watery
Only portions of the stool are soft or watery
Diarrhea with each bowel movement
Only 1 or 2 bowel movements per day
More than 4 bowel movements per day
Amount
- None -
Increased, large amount of stool
Decreased or normal, small amount of stool
Color
- None -
Stool is dark brown in color
Stool is very pale in color
Stool is black and tarry in appearance
Miscellaneous
- None -
Thick mucous or pieces of tissue present in stool
Loss of bowel control (defecates in the house on the floor)
Severe straining when having a bowel movement
Is your dog/cat’s appetite normal? If not, is he eating at all? What have you been feeding your dog/cat in the last week? Include dog or cat foods, treats, table foods, milk, and anything else that you have fed your pet.
Does your dog have access to foods other than what you feed it?
- None -
Yes
No
If so, what?
Has there been a diet change in the last few weeks?
- None -
Yes
No
If so, does that correspond with the onset of the diarrhea?
Is your dog as active as normal?
- None -
Yes
No
Describe any change in water consumption.
- None -
Increased
Decreased
Has your pet vomited? If so, how frequently and for how long?
Does your pet go outside your house?
- None -
Yes
No
Does your pet go outside your yard?
- None -
Yes
No
Does your pet have access to garbage cans, either within your house or yard or outside your yard?
- None -
Yes
No
Does your pet have toys that it plays with that it could have swallowed?
- None -
Yes
No
Does your pet have access to sewing materials, such as thread or needles, rubber bands, or string?
- None -
Yes
No