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Noah's Ark Vet - Diarrhea/Loose Stool Questionnaire
1
First Name
Last Name
Date
Phone
Email
How long has the diarrhea/loose stool been present?
Is the diarrhea more severe now than a few days ago?
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2
Watery Stool
Stool is the thickness of pancake batter
Watery Stool
Stool is the thickness of pancake batter
Consistency
Very bloody stool
Only sporadic blood present
Blood not present in stool
Bright red blood present
Dark, tarry blood present
Very bloody stool
Only sporadic blood present
Blood not present in stool
Bright red blood present
Dark, tarry blood present
Blood
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
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
Degree/Frequency
Increased, large amount of stool
Decreased or normal, small amount of stool
Increased, large amount of stool
Decreased or normal, small amount of stool
Amount
Stool is dark brown in color
Stool is very pale in color
Stool is black and tarry in appearance
Stool is dark brown in color
Stool is very pale in color
Stool is black and tarry in appearance
Color
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
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
Miscellaneous
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3
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.
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4
Yes
No
Yes
No
Does your dog have access to foods other than what you feed it?
If so, what?
Yes
No
Yes
No
Has there been a diet change in the last few weeks?
If so, does that correspond with the onset of the diarrhea?
Yes
No
Yes
No
Is your dog as active as normal?
Increased
Decreased
Increased
Decreased
Describe any change in water consumption.
Has your pet vomited? If so, how frequently and for how long?
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5
Yes
No
Yes
No
Does your pet go outside your house?
Yes
No
Yes
No
Does your pet go outside your yard?
Yes
No
Yes
No
Does your pet have access to garbage cans, either within your house or yard or outside your yard?
Yes
No
Yes
No
Does your pet have toys that it plays with that it could have swallowed?
Yes
No
Yes
No
Does your pet have access to sewing materials, such as thread or needles, rubber bands, or string?
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