Diarrhea Questionnaire Client NamePatient NamePhoneEmail How long has the diarrhea been present?Is the diarrhea more severe now than a few days ago?YesNoPlease 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 DescribeIs your cat's appetite normal?YesNoIf not, is it eating at all?YesNoWhat 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?YesNoDescribe:Has there been a significant diet change in the last few weeks?YesNoIf so, does that correspond with the onset of the diarrhea?First ChoiceSecond ChoiceThird ChoiceIs your cat as active as normal?YesNoDescribe any change in water consumption (increased or decreased):Has vomiting been occurring?YesNoHow frequently and for how long?Does your cat go outside your house?YesNoIf so, does the cat go outside the yard?YesNoDoes your cat have access to garbage cans, either within your house or yard or outside your yard?YesNoDescribe:Does your cat have play-toys that could have been swallowed?YesNoDescribe:Does your cat have access to sewing materials, such as thread or needles, or rubber bands, or string?YesNoDescribe:Do you have other dogs or cats that live with this one?YesNoIf so, does the other pet have diarrhea?Do any of the other members of your family currently have a diarrhea problem?YesNoCommentsThis field is for validation purposes and should be left unchanged.
