Feline House-soiling Form

Feline House-soiling Form
Name

First NameLast Name
Pronoun
He/ She/ They
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Name
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
Please describe
How to you think your pets get along?
Does your cat go outside?
Do you have a cat door or flap to the outdoors?
Type?
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?

YesNo
Please Describe
How many litter boxes in your home
What type of litter are they?
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

Tice DailyDailyWeeklyOther
How often?
What type of litter do you use?

Fine grainNon-clumpingCoarse granulesWood or paper based pelletsScentedSilica granules or beadsCorn or wheat-basedGarden soilOther
Please describe
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?

NormalLarge volumeSmall volumeStrong odorSticky consistencyBloodyPassed more/less frequently than usual
If your cat defecates when house-soiling, how would you describe the stools?

NormalSmall & hardSoft & wateryBlood/mucusFormed in part, then softerOther
Please describe
How long has the house-soiling been occurring
Do you remember the first incident?

YesNo
Please describe
What surfaces are targeted?

CarpetWoodVinylTileBedding/ClothingBath/Shower/SinkA particular family memberOther
Please Describe
Is your cat targeting vertical surfaces with urine?
Please describe
How often is he house-soiling occurring?
Please describe
How has the frequency changed since the problem started?
Have there been any changes recently (or around when the house-soiling started?)

Moved to a new homeNew baby or petAbsence of family member/petOther (including work/school schedule changes
Please describe
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)?
Please describe
Is your cat easy to medicate
What are your preferred formulations for medications

PillsMedication in foodOral liquidsTransdermal 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: