Feline Inappropriate Elimination Questionnaire

Age_______ Sex_______ Neutered Y N

Size, weight, coat length: ___________ Number of cats in household________

Duration of house-soiling (days, weeks, months, years) _______(approximately when did the problem start?)

How often does your cat urinate out of the litter box _________________________

How often does your cat defecate out of the litter box ________________________

General behavior (any change) List: (reclusive, lethargic, irritable, clingy, etc.)



Physical, health, or medical problems, list:



Medications (including flea and heartworm treatment), list



Check One:

Urine___, Stool____, Both___

Urination posture: Squat____, Stand_____

Surface position of urine: Horizontal__ (example rug, bed) Vertical__(example walls, backs of chairs)

Volume of urine: Small_____, Average (normal bladder volume), _____ Large______

On the reverse of this sheet, or a separate sheet of paper, please give us a rough diagram of your home, with litterbox and inappropriate elimination locations marked.

Location(s): Diagram on reverse side: ____

Number of litter boxes: ______ Change in number_____

Type(s) of litter boxes and number of each type, e.g. open, covered, automatic.



Recent change in type of box Y N Size of litter boxes___________________

Litter brand: ____________________________

Litter type(check one) Clay_____ Clumping/sandy ______ Scented ________ Unscented ________

Check if recent litter change_____

Litter Liner used? Y N

Litter deodorizer, what brand if used ______________________

Litter maintenance: Scooping frequency_____________ Refresh frequency(how often do you add more litter?) __________________

Empty/replace frequency________________ Washing frequency__________________

Cleaning solution used_____________ fragrance of solution_______________________

Location(s) of boxes: Diagram on reverse side_____________________________

Recent litter box location change Y N

Behavior associated with litter box (remote video HELPFUL). Check all that apply:

Stands in box: _______ Squats in box: _______ Straddles box: ________ Meows_______

Shakes paws______ Runs away quickly after_____ Scratches litter before urinations____

Scratches litter after urination_______ Scratches litter before defecation______

Scratches litter after defecation______ Scratches other surfaces/objects______

What surfaces/objects (list)_______________________

Describe behavior when approaching box e.g. relaxed, slow, cautious etc,

_____________________________________________________________________________

_____________________________________________________________________________

Describe behavior when leaving box: _______________________________________________

______________________________________________________________________________

______________________________________________________________________________

How serious is this problem to you: Severe________ Moderate________ Mild________