ARLINGTON CAT CLINIC – Inappropriate elimination

1
What day and time is your appointment? * This field is required.
Date
Month
Day
Year
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2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
2
First Name
Last Name
Patient Name
3
Email
Primary Phone
Home
Cell
Work
Urine
Stool
Both
Is your cat having
Outside the litterbox?
When did the problem start?
Better
Worse
Staying the same
Is it getting
4
Daily
Every few days
Weekly
Just occasionally
How often does the problem occur?
Squat
Stand
Don't know
When urinating outside the box does your cat
How many litter pans are available?
Locations
Are the boxes covered or uncovered
Scented
Unscented
What brand of litter is used?
Baking soda
Deodorizers
Nothing
Do you add
5
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)
6
Where do the accidents occur?
Pillows
Plastic
Carpet
Clothing
Furniture
Tile
Other
Does the cat have a preference for going on certain surfaces?
If other, Please Specify
What have you used to clean the areas?
Has your cat had a bad experience near the litter-box?
If so, please explain
7
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)
8
I am in this vehicle* This field is required.
( Please list model and color )
9
Best phone number for today's appointment* This field is required.
( The veterinarian and technician will use this number to communicate with you through the appointment. )
10
Primary reason for Appointment / Concern ( Please be as detailed as possible. )* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
List Medications your pet is currently taking
Huge
Large
Normal
Small
Ok
Ok
12
Do you need refills of any of these Medications?
YESNO
13
Do you need refills on any prescription pet food?
YESNO
Should be Empty: