ARLINGTON CAT CLINIC – Inappropriate Elimination

1
What day and time is your appointment?
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
What day and time is your appointment?* This field is required.
Appointment Date
Appointment Time
3
First Name
Last Name
Patient Name
4
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
5
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
6
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)
7
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
8
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)
Should be Empty: