Feline House-soiling Form
Name
First Name
Last Name
Pronoun
He/ She/ They
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet Name
Reason for Visit
Total number of people in the home
How does your cat interact with family members?
Please Select
Friendly
Aggressive
Nervous
Avoids Contact
Who is your cats favorite person
How does your cat interact with strangers
Please Select
Friendly
Aggressive
Nervous
Avoids Contact
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 Select
Playing Together
Sleeping Together
Mutual Grooming
Being Aggressive (hissing, growling, swiping)
Running away
Please describe
How to you think your pets get along?
Does your cat go outside?
Please Select
Yes
No
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?
Please Select
Yes
No
Type?
Can your cat see other animals from inside your home?
Please Select
Yes
No
Please describe (ie, cats, birds at feeder, etc)
What type of food do you feed your cat?
Please Select
Canned
Dry
Both
What brand of food are you feeding?
Have you changed the food recently?
Yes
No
Please Describe
How many litter boxes in your home
What type of litter are they?
Please Select
Open
Hooded or Covered
Automatic
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 Daily
Daily
Weekly
Other
How often?
What type of litter do you use?
Fine grain
Non-clumping
Coarse granules
Wood or paper based pellets
Scented
Silica granules or beads
Corn or wheat-based
Garden soil
Other
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?
Normal
Large volume
Small volume
Strong odor
Sticky consistency
Bloody
Passed more/less frequently than usual
If your cat defecates when house-soiling, how would you describe the stools?
Normal
Small & hard
Soft & watery
Blood/mucus
Formed in part, then softer
Other
Please describe
How long has the house-soiling been occurring
Do you remember the first incident?
Yes
No
Please describe
What surfaces are targeted?
Carpet
Wood
Vinyl
Tile
Bedding/Clothing
Bath/Shower/Sink
A particular family member
Other
Please Describe
Is your cat targeting vertical surfaces with urine?
Please Select
Yes
No
Please describe
How often is he house-soiling occurring?
Please Select
Once Daily
Multiple Times Daily
Weekly
Other
Please describe
How has the frequency changed since the problem started?
Please Select
Increased
Decreased
Remained the same
Don't know
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 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 Select
Yes
No
Please describe
Is your cat easy to medicate
Please Select
Yes
No
What are your preferred formulations for medications
Pills
Medication in food
Oral liquids
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).
Submit
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