780-250-1700
2531 – 17th Street NW Edmonton, AB
Links
Become A Client
Surrender Consent Form
Hit enter to search or ESC to close
Home
Contact
New Clients
What to Expect
New Client Registration Form
Prescription/Food Refill Request
About Us
Team and Pet Bios
Location & Hours
Make an Appointment
Fear Free Clinic
Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Nutritional Counseling
Additional Services
Pet Health
Pet Health Library
Pet Health Checker
How-To Videos
News
Forms
Consent Forms
General Anesthesia Consent
Euthanasia Consent Form
Echocardiogram – Drop Off Consent Form
Drop Off Consent Form – with sedation
Drop Off Consent Form
Overnight Hospitalization – Drop Off Consent Form
Blood Glucose Curve – Drop Off Consent Form
Dental Surgery Consent Form
Spay/Neuter Surgery Consent Form
Telemedicine Consent Form
Ultrasound Consent Form
Admission Forms
Canine Patient Admission Form
Feline Patient Admission Form
Recheck Exam Admission Form
Questionnaires
Diarrhea Questionnaire
Vomiting Questionnaire
Itching Questionnaire
Canine Cognitive Dysfunction Syndrome Assessment
Shop Online
Diarrhea Questionnaire
Date
*
Date Format: MM slash DD slash YYYY
Client Name
*
First
Last
Pet Name
*
How long has the diarrhea been present?
*
Please describe whether it has been days/weeks/months
Has the diarrhea become more severe now than a few days ago?
*
More severe
Less severe
The same
From the list below, circle each item that applies: Consistency
*
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
From the list below, circle each item that applies: Blood
*
Very bloody stool
Only occasional, small amount of fresh blood present
Blood not present in stool
Bright red blood present
Dark, tarry blood present
From the list below, circle each item that applies: 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)
From the list below, circle each item that applies: 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
From the list below, circle each item that applies: Color
*
Stool is dark brown in color
Stool is very pale or tan to yellow in color
Stool is black and tarry in appearance
From the list below, circle each item that applies: Miscellaneous
*
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
Is your pet’s appetite normal?
*
Yes
No
If not, is it eating at all?
Yes
No
What have you been feeding your pet 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.
*
Does your pet have access to foods other than what you feed it? If so, what:
*
Has there been a change in your pet’s diet in the last few weeks? Yes / No. If so, how soon after the change did the diarrhea occur?
*
Is your pet as active as normal or does it appear more tired or lethargic?
*
Yes
No
Describe any change in water consumption:
*
Increased
Decreased
No change
Has your pet vomited? If so, how frequently and for how long?
*
Does your pet go outside your house unattended?
*
Yes
No
Does your pet go outside your yard unattended?
*
Yes
No
Does your pet have access to garbage cans or discarded food, either within your house or yard or outside your yard?
*
Yes
No
Does your pet have toys that it plays with that it could have swallowed? If so, what?
*
Does your pet have access to sewing materials, such as thread or needles, rubber bands, or string?
*
Yes
No
Do you have other dogs or cats that live in the same environment? If so, do any of the other pets have diarrhea or illness?
*
Yes
No
Do any of the members of your family currently have a diarrhea problem?
*
Yes
No
Home
Contact
New Clients
What to Expect
New Client Registration Form
Prescription/Food Refill Request
About Us
Team and Pet Bios
Location & Hours
Make an Appointment
Fear Free Clinic
Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Nutritional Counseling
Additional Services
Pet Health
Pet Health Library
Pet Health Checker
How-To Videos
News
Forms
Consent Forms
General Anesthesia Consent
Euthanasia Consent Form
Echocardiogram – Drop Off Consent Form
Drop Off Consent Form – with sedation
Drop Off Consent Form
Overnight Hospitalization – Drop Off Consent Form
Blood Glucose Curve – Drop Off Consent Form
Dental Surgery Consent Form
Spay/Neuter Surgery Consent Form
Telemedicine Consent Form
Ultrasound Consent Form
Admission Forms
Canine Patient Admission Form
Feline Patient Admission Form
Recheck Exam Admission Form
Questionnaires
Diarrhea Questionnaire
Vomiting Questionnaire
Itching Questionnaire
Canine Cognitive Dysfunction Syndrome Assessment
Shop Online
Contact Us
Name
*
First
Last
Email
*
Phone
*
Pet Name
*
Preferred Date
*
MM
DD
YYYY
Preferred Time
*
:
HH
MM
AM
PM
Reason for appointment
*