1. How long has the diarrhea been present? ____________ hours / days / weeks
2. Has the diarrhea become more severe now than a few days ago? More severe / Less severe / Same
3. From the list below, circle each item that applies:
- Watery stool
- Stool is the thickness of pancake batter (is very runny and spreads out)
- Stool has the consistency of a cow patty
- Stool is semi-formed
- Very bloody stool
- Only occasional, small amount of fresh blood present
- Blood not present in stool
- Bright red blood present
- Dark, tarry blood present
Degree and Frequency
- Entire bowel movement is soft or watery
- Stool starts out formed and becomes runny at the end
- Only portions of the stool are soft or watery
- Diarrhea is present with each bowel movement
- Only 1 or 2 bowel movements per day - diarrhea or normal
- More than 4 bowel movements per day - diarrhea or normal
- Diarrhea is occasional (some bowel movements each day are normal)
First bowel movements are normal
First bowel movements are diarrhea
Last bowel movements are normal
Last bowel movements are diarrhea
Amount of Feces or Diarrhea
- Large amount of stool produced with each bowel movement
- More frequent bowel movements with normal volume each time
- Increase in both frequency and volume
Decreased or normal amounts of stool
- Stool is dark brown in color
- Stool is very pale or tan to yellow in color
- Stool is black and tarry in appearance
- Thick mucus or gel coating on the stool
- Pieces of tissue present in stool
- Stool is extremely smelly
- Loss of bowel control (defecates in the house on the floor)
- Severe straining when having a bowel movement
4. Is your dog's appetite normal? Yes / No. If not, is it eating at all? Yes/No.
5. What have you been feeding your dog during the last week? Include dog or cat foods, treats, table foods, milk, and anything else that you have fed your pet. Also state approximately what percentage of the diet is each item or category.
6. Does your dog have access to foods other than what you feed it? If so, what?
7. Has there been a change in your dog's diet in the last few weeks? Y / N. If so, how soon after the change did the diarrhea occur? ________________________________
8. Is your dog as active as normal or does it appear more tired or lethargic?
9. Describe any change in water consumption: Increased / Decreased / No change
10. Has your pet vomited? If so, how frequently and for how long?
11. Does your dog go outside your house unattended?
12. Does your dog go outside your yard unattended?
13. Does your dog have access to garbage cans or discarded food, either within your house or yard or outside your yard?
14. Does your dog have toys that it plays with that it could have swallowed? If so, what?
15. Does your dog have access to sewing materials, such as thread or needles, rubber bands, or string?
16. Do you have other dogs or cats that live in the same environment? If so, do any of the other pet(s) have diarrhea or illness? Y / N
17. Do any of the members of your family currently have a diarrhea problem?
18. Is there a phone number where we can reach you or your spouse today if we need further information?