Diarrhea Questionnaire Client Name Patient Name PhoneEmail How long has the diarrhea been present? Is the diarrhea more severe now than a few days ago? Yes No Please describe: Check each item that applies:Consistency Watery stool Stool is about the thickness of pancake batter or pudding Blood Very bloody stool Only sporadic blood present Blood not present in stool Bright red blood present Dark, tarry blood present Degree Entire stool is soft or watery Only portions of the stool are soft or watery Frequency Only 1 or 2 bowel movements per day More than 4 bowel movements per day Color Stool is dark brown in color Stool is very pale in color Stool is black and tarry in appearance Miscellaneous Thick mucus 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 Other Describe Is your cat's appetite normal? Yes No If not, is it eating at all? Yes No What have you been feeding your cat during the last week? (Include dog or cat foods, treats, table foods, milk, and anything else that it gets on a daily basis. Also state what percentage of the diet is each item or category.)Does your cat have access to foods other than what you feed it? Yes No Describe: Has there been a significant diet change in the last few weeks? Yes No If so, does that correspond with the onset of the diarrhea? First Choice Second Choice Third Choice Is your cat as active as normal? Yes No Describe any change in water consumption (increased or decreased): Has vomiting been occurring? Yes No How frequently and for how long? Does your cat go outside your house? Yes No If so, does the cat go outside the yard? Yes No Does your cat have access to garbage cans, either within your house or yard or outside your yard? Yes No Describe: Does your cat have play-toys that could have been swallowed? Yes No Describe: Does your cat have access to sewing materials, such as thread or needles, or rubber bands, or string? Yes No Describe: Do you have other dogs or cats that live with this one? Yes No If so, does the other pet have diarrhea? Do any of the other members of your family currently have a diarrhea problem? Yes No PhoneThis field is for validation purposes and should be left unchanged.
