Feline Inappropriate Elimination Questionnaire

Owner's Name:
Contact phone #:

Please answer as many questions as you can as it pertains to your cat that is eliminating outside of its box.

Name

Age/birthdate

Gender: Male   Female  |   Spayed/Neutered 

Number of pets in house:
    Cats
    Dogs Do they have access to the litter boxes? Yes   No
    OthersPlease list

Does this cat go outside? Yes  No

What is the cat's current weight? , coat length ?

How long has the inappropriate elimination been happening?

Does the cat:
    Defecate in or out of the box? In Out
    Urinate in or out of the box? In Out

Please describe this cat's general behavior. (reclusive, lethargic, scared, timid, irritable, clingy, etc.)


Has there been any change in its behavior?


If aggressive, is the behavior directed toward any specific person, object, animal?


Please list any current and/or past physical and medical problems?


Please list all medications (over the counter, prescriptions, flea & tick preventatives) that your pet is currently on.


If your cat is urinating out of the box, please answer the following
    How often is it urinating outside of the box?
    What is the cat's posture as it's urinating? Squat/stand?
   
    Is the urine on a vertical (wall, door) or horizontal (floor, bed) surface?
   
    What is the volume of urine?  Small   Average Large

    Location of inappropriate urination (surface? room?)
   

If your cat is defecating out of the box, please answer the following
    How often is the cat defecating outside of the box?
    What is the size and consistency of the stool?
   
    Location of inappropriate defecation (surface? room?)
    
 
Information on litter and litter boxes
    Number of boxes:
    Have you recently made a change in number of boxes, added or removed? When?
   
    Types of boxes, number of each (open, closed, auto)
   
    Size of boxes
   
    Do you use multiple brands of litter or stay with one brand?
   
    Please list brands
   
    What type of litter do you use?
    Scoopable   Regular Clay Wheat PaperOther
     If other, please list:

    How deep do you fill the box? inches
    Recent changes?
   
    Do you use a liner?
    Which brand?
    Do you use a deoderizer?
    Which brand?
    How often do you scoop litter?
    How often do you add new litter?
    How often do you completely replace all litter?
    How often do you wash the box?
    What cleaner do you use to wash the box?

Pleast list in detail the location(s) of boxes, including adjacent appliances and furniture.


Please answer the following questions about you cat's behavior while using the litter box. (Consider a remote video if possible) Please check all of the following if seen:
    Stands in box
    Squats in box
    Straddles box
    Meows while in box
    Shakes paws
    Runs away quickly after
    Scratches litter before urination
    Scratches litter after urination
    Scratches litter before defecation
    Scratches litter after defecation
    Scratches other surfaces/objects (i.e. Side of box, just outside of box, carpet)
            List other surfaces:
           
    Describe behavior when approaching box: relaxed, slow, cautious, etc
   
    Describe behavior when leaving box   
   

How serious is this problem to you?


What is the cat's current diet (wet, dry, both) please include treats and people food and amount and frequency


Is your home multi-level or ranch style?

In what order did this cat enter the household? (first, second, third, etc.)

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