Client Name *

First

Last

Date *

How long has the diarrhea been present? *

Is the diarrhea more severe now than a few days ago? *

Yes
No

If yes please describe *

Select below each item that applies:

Consistency

Watery stool
Stool is about the thickness of pancake batter or pudding

Blood

Degree

Entire stool is soft or watery
Only portions of the stool are soft or watery

Frequency

Diarrhea with each bowel movement
Diarrhea is sporadic (some bowel movements are normal)
Only 1 or 2 bowel movements per daym. 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)s.
Severe straining when having a bowel movement.
Other:

Please Specify Other:

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, tablefoods, 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

If so, what?

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?

Yes
No

Is your cat as active as normal?

Yes
No

Describe

Describe any change in water consumption (increased or decreased)

Has vomiting been occurring? *

Yes
No

If so, 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

If so, describe

Does your cat have play-toys that could have been swallowed? *

Yes
No

If yes, describe

Does your cat have access to sewing materials, such as thread or needles, or rubber bands, or string? *

Yes
No

If yes, 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 members of your family currently have diarrhea? *

Yes
No

I hereby authorize The Cat Doctor of Monroe and Dr. Kimberly Scutchfield to perform care for my pet. I acknowledge that I am the owner/appointed caregiver of the animal described above and am legally able to consent to care for my pet. I understand that any procedure poses a risk to my pet regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. I further authorize The Cat Doctor of Monroe and staff to release my pet's medical records to another veterinary provider if requested by another veterinary provider.

I understand staff will contact me after they have examined my cat to discuss recommended diagnostics and treatment and will provide an initial estimate of charges. I can be reached at

Phone *

Or Phone

If I cannot be reached at this number, I authorize initial diagnostics - including radiographs and blood work if indicated for my cat. Further, if I cannot be reached, I authorize initial treatment - including fluid support and other supportive medications as indicated for my cat. If I cannot be reached, I authorize sedation if needed for treatment either due to the nature of the problem or my cat’s aggression. I understand that sedation and anesthesia pose a risk to my pet, regardless of health status. If my cat is dropped off, I understand my cat will be treated for fleas if evidence of infestation is found today and I will be responsible for that cost.

I understand payment is due when my cat is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for my cat.

Payment is expected at the time of service. How will you be paying today? *

Cash
Credit/Debit
Check
Care Credit - minimum $200 transaction

Signature *

Date *

Diarrhea Questionnaire

Diarrhea Questionnaire

Location

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Hours

We are a cat-only veterinary hospital in Monroe, MI.

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