Gastrointestinal Questionnaire | Suburban Veterinary Clinic

Pet Name*

Diarrhea (please answer the appropriate questions)

Does your pet have diarrhea?*

Yes

I don't know

How long has your pet had diarrhea?

Is the diarrhea...

getting worse

getting better

staying the same

Describe the consistency of the stool.

Water/liquid

Soft

Normal

Firmer than normal

Other

What is the color of your pets stool?

Brown

Yellow

Green

Black

Red

Other

Have you noticed blood in the stool

Yes

I don't know

Have you noticed mucus in the stool?

Yes

I don't know

Does your pet strain during its bowel movements?

Yes

I don't know

Have you noticed an increased frequency in your pet's bowel movements?

Yes

I don't know

Have you noticed any intestinal parasites (worms) in your pet's stool

Yes

If yes what do they look like?

Spaghetti

Rice

Other

Vomiting (please answer the appropriate questions)

Is your pet vomiting?*

Yes

How long has your pet been vomiting?

How frequently is your pet vomiting?

Is the vomiting...

getting worse

getting better

staying the same

What is in the vomit?

Bile (yellow fluid)

Blood

Foam

Food

Other

Describe your pet's appetite:

Normal

Increased

Decreased

Not eating

Describe you pet's water intake:

Normal

Increased

Decreased

Not drinking

General Information

What do you feed your pet? Include treats and table food if applicable:*

What is your pet's activity level?

Normal

Increased

Decreased

Does your pet go outside?*

Yes

If yes, is your pet supervised while it is outside?

Always

Sometimes

Never

Does your pet have any unusual cravings?*

Grass

Dirt

Rocks

Fabric

String

Metal

Rubber bands

Plastic

Feces

Other

Are there any other pets in the household?*

Yes

If yes, are any of them vomiting or experiencing diarrhea?

Yes

Does your pet have excessive gas (flatulence)?*

Yes