Feline House-soiling Form
He/ She/ They
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Reason for Visit
Total number of people in the home
How does your cat interact with family members?
Who is your cats favorite person
How does your cat interact with strangers
Name and age of other cats in the home. Please list them in order they arrived in the home.
Others pets (Species, breeds and ages)
If you have other cats or pets in the household, have you recently seen your cat responding to them in any of the following ways
Being Aggressive (hissing, growling, swiping)
How to you think your pets get along?
Does your cat go outside?
Occasionally Sneaks Out
Goes Outside Supervised
Goes Outside Unsupervised
Has Pen or Outside Enclosure
Do you have a cat door or flap to the outdoors?
Can your cat see other animals from inside your home?
Please describe (ie, cats, birds at feeder, etc)
What type of food do you feed your cat?
What brand of food are you feeding?
Have you changed the food recently?
How many litter boxes in your home
What type of litter are they?
Hooded or Covered
Are liners used? And what kind?
Are deodorizers used? And what kind?
Average size of litterbox?
Who scoops the litterbox?
How often to you clean the litterbox
What type of litter do you use?
Wood or paper based pellets
Silica granules or beads
Corn or wheat-based
How often do you wash the litter box and what cleaning products do you use?
If your cat urinates when house-soiling, how would you describe the urine?
Passed more/less frequently than usual
If your cat defecates when house-soiling, how would you describe the stools?
Small & hard
Soft & watery
Formed in part, then softer
How long has the house-soiling been occurring
Do you remember the first incident?
What surfaces are targeted?
A particular family member
Is your cat targeting vertical surfaces with urine?
How often is he house-soiling occurring?
Multiple Times Daily
How has the frequency changed since the problem started?
Remained the same
Have there been any changes recently (or around when the house-soiling started?)
Moved to a new home
New baby or pet
Absence of family member/pet
Other (including work/school schedule changes
Please detail what you have been doing to clean the soiled areas?
Have you used any punishment in response to the house-soiling (eg, rubbing nose in the urine or stool, spanking, water pistol, shouting, confinement)?
Is your cat easy to medicate
What are your preferred formulations for medications
Medication in food
Transdermal gel (where availale)
Draw a basic house floor plan on a separate sheet. This is very important but it does not have to be to perfect scale. Mark all items listed below on the house floor plan so we can get a feeling for the environment where your cat lives (a) = Litter box locations (b) = House-soiling locations (c) = Windows and doors (d) = Scratching post locations (e) = Food and water bowl locations (f) = Cat doors or flaps. Please number the house-soiling locations in chronological order in terms of when you became aware of deposits in those locations (eg, b1, b2, etc).
Should be Empty: