Inappropriate Elimination
Appointment Date
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Month
-
Day
Year
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Time
Hour Minutes
AM
PM
AM/PM Option
Name
*
First Name
Last Name
Patient Name
*
Email
*
example@example.com
Primary Phone
*
Please enter a valid phone number.
Primary Phone Type
*
Please Select
Home
Cell
Work
Is your cat having
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Urine
Stool
Both
Outside the litterbox?
When did the problem start?
Is it getting
Please Select
Better
Worse
Staying the same
How often does the problem occur?
Please Select
Daily
Every few days
Weekly
Just occasionally
When urinating outside the box does your cat
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Squat
Stand
Don't know
How many litter pans are available?
Locations
Are the boxes covered or uncovered
What brand of litter is used?
Please Select
Scented
Unscented
Do you add
Please Select
Baking soda
Deodorizers
Nothing
Before this problem started were there any changes in
Litter
Location of the box
Type of litter-box
Other changes(pets, people, redecorating, new residence)
Where do the accidents occur?
Does the cat have a preference for going on certain surfaces?
Please Select
Pillows
Plastic
Carpet
Clothing
Furniture
Tile
Other
If other, please specify
What have you used to clean the areas?
Has your cat had a bad experience near the litter-box?
Yes
No
If so, please explain
What do you do as punishment, if any?
What methods have you tried for the problem?
Have they helped?
Is the cat currently on medication (specify medicine)
Have you noticed any abnormalities to the urine or stool?( blood, mucus, loose stool)
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