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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
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Watery Stool
Stool is the thickness of pancake batter
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Watery Stool
Stool is the thickness of pancake batter
Consistency
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Very bloody stool
Only sporadic blood present
Blood not present in stool
Bright red blood present
Dark, tarry blood present
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Very bloody stool
Only sporadic blood present
Blood not present in stool
Bright red blood present
Dark, tarry blood present
Blood
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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
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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
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Increased, large amount of stool
Decreased or normal, small amount of stool
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Increased, large amount of stool
Decreased or normal, small amount of stool
Amount
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Stool is dark brown in color
Stool is very pale in color
Stool is black and tarry in appearance
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Stool is dark brown in color
Stool is very pale in color
Stool is black and tarry in appearance
Color
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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
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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
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Yes
No
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Yes
No
Does your dog have access to foods other than what you feed it?
If so, what?
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Yes
No
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Yes
No
Has there been a diet change in the last few weeks?
If so, does that correspond with the onset of the diarrhea?
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Yes
No
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Yes
No
Is your dog as active as normal?
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Increased
Decreased
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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
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Yes
No
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Yes
No
Does your pet go outside your house?
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Yes
No
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Yes
No
Does your pet go outside your yard?
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Yes
No
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Yes
No
Does your pet have access to garbage cans, either within your house or yard or outside your yard?
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Yes
No
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Yes
No
Does your pet have toys that it plays with that it could have swallowed?
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Yes
No
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Yes
No
Does your pet have access to sewing materials, such as thread or needles, rubber bands, or string?
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