FECAL QUESTIONNAIRE

Client Name *

First

Last

E-mail *

Phone *

Would you prefer we provide test results by email or phone? *

Patient Name *

Patient Species *

Have you seen any worms? If so, please describe:

What is the consistency of the stool?

How long has the problem been going on?

Is your pet on Heartworm medication?

Is there a history of allergies?

What type of food do you feed?

Have you changes food brand/type recently?

Has he/she had anything to eat that is not part of the usual diet? If yes, describe:

Has he/she been on any medications? If yes, please list:

Is this a recheck to make sure the problem has been eradicated?

When was the sample collected?

Name