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FECAL QUESTIONNAIRE
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Client Name
*
First
Last
E-mail
*
Phone
*
Would you prefer we provide test results by email or phone?
*
Email
Phone
No Preference
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?
Yes
No
When was the sample collected?
Name
SUBMIT