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  • Behavior Questionnaire-Inappropriate Urination

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    WHO SHOULD USE THIS FORM:

    Please fill out this form to the best of your ability, and submit. The information you give us will help to diagnose the reason for the behavior, and help us to give you suggestions on how to eliminate the inappropriate behavior.

    Owner Information:

    *=required

    * Name:

    *Main Phone:

    Alternate Phone:

    * Email Address:

    Map drawing/video with litter box location(s) and other helpful information

    Please draw a map of your home to bring to your appointment. Including the following information on the map as well (or providing a good video with this information) can be very helpful to us in working with you to resolve issues with elimination outside the box:

    1) Locations of each litter box (assign a number to each box if more than one)
    2) Exact dimensions of each numbered box
    3) Presence or absence of a hood on each of the boxes (H=hood, NH= no hood); if box is a top loader, indicate TL
    4) Type of litter in each box if differs by box (questionnaire below will ask for more specific information regarding type of litter)
    5) Location of all screen doors, inside doors, and front and back doors
    6) Location of washer and dryer
    7) Note any furniture that is in the vicinity of each of the boxes
    8) Indicate which windows or doors give your cat(s) visual access to the outside
    9) Indicate all areas where you have found urine or stool outside the box
    10) Regarding #9 above, also indicate whether the urine or stool outside the box is occurring on a flat surface (carpet, throw rug, tile or hardwood floor, clothes on the floor, plastic or paper on floor, etc.), or on a vertical surface (the wall, inside of a door, curtains, etc.), or both
    11) Indicate which portion of the house each cats tends to spend most of his or her time, and if the area is an elevated surface (cat tree, window sill, counter top, etc.)
    12) Indicate locations of all cat food bowls and all water bowls
    13) If more than one litter box, prioritize them as to which box(es) are used most frequently (i.e, #1 = used most frequently; highest number should indicate box that is used the least; if all boxes are used equally, rate them all a '1'). Also indicate if individual cats use one or more boxes more than the other boxes
    14) Age of each of the boxes

    Behavior Questionnaire:

    How many cats are in your home:

    Number of males:

    Number of females:

    Are all of the males in the home neutered:

    Yes

    No

    Are all of the females in the home neutered (spayed):

    Yes

    No

    What are the ages of all your cats:

    Do you have any Dogs or other pets in your home:

    Yes

    No

    Do you see stray/feral/or owned cats frequently in your neighborhood? Or specifically in your yard:

    Yes

    No


    What is the total number of litter boxes in your home:

    What type of litter do you use:

    Clumping

    Gravel

    Litter Pearls

    Wheat-based

    Corn-based

    Yesterday's News

    Varies by litter box (see map)

    Have you changed types or brands of litter recently:

    Yes

    No


    How often do you remove soiled urine clumps from the litter box(es):

    How often do you remove solid waste from the litter box(es):

    Do you ever "top off" with fresh litter after you have removed solid or urine waste:

    Yes

    No


    How often do you completely dump all the litter, clean the litter box and replace with completely fresh litter:

    Are deodorants used in the cleaning process:

    Yes

    No


    Are room fresheners used in or near your litter box:

    Yes

    No


    How many cats actually share a litter box:

    Are liners ever used in your litter boxes:

    Yes

    No


    If liners are used, are they scented:

    Yes

    No


    Do your litter boxes have hoods:

    All boxes have hoods

    Not all boxes have hoods

    No boxes have hoods

    Describe cat’s behavior in the litter box: does he get in, does he stand outside, does he dig in or out, does he get in and out as quickly as possible, or does he spend a lot of time digging around both before and after urinating or defecating, are all four of his feet in the litter box when he is using it, etc…

    Are you using a litter that allows you to flush after scooping the soiled portions from your litter box:

    Yes

    No


    If not, do you dispose of the soiled litter out of doors? How long after it has been scooped is it taken outside:

    How deep (in inches) is the litter in the box(es):
    (include this information, by box #, on your map)

    List all the types of litter used for each box:

    Are any of the litters used scented:

    Yes

    No


    Does the cat(s) respond differently to any of the different styles of boxes or litters, or sizes of box and depths of litters:

    Is the cat ever allowed outside:

    Yes

    No


    Does the cat eliminate in the presence of other animals or people:

    Yes

    No


    Has the cat ever had any variation in whether or not he covers his feces or urine, and is any of that variation associated with the presence or absence of any other situation or cat:

    Does the cat ever vocalize while he eliminates:

    Yes

    No


    Will the cat spray against the back of a covered or tall-backed litter box? Or on the wall against which the litter box sits:

    Yes

    No


    Does the cat ever use a shower or a bathtub for elimination:

    Yes

    No


    If so, how frequently:

    When did you first notice the occurrence of inappropriate urination/defecation:

    Were there any events that you may be aware of that may have precipitated the start of this behavior? (New child in home, visitors in home, owners on vacation just prior to or at the time of the occurrence of the inappropriate behavior, construction in home, inadvertent lack of access to litter boxes, loud noise that occurred just as the cat was in the box, owner recently changed hours worked and therefore cat’s routine has changed, owner going through stressful time, new cat or dog in home, etc…):

    If your cat is inappropriately urinating, how would you describe the amount of urine:

    Small

    Normal

    Large

    Do you see any visible blood in the urine:

    Yes

    No


    Does your cat consistently urinate (defecate) outside the litter box or will he/she sometimes use the box:

    Has your cat ever been on any medication for his/her inappropriate elimination:

    Yes

    No


    If you answered ‘yes’ to the above question, please name the medication(s), dosage(s), length of time that your cat was/has been on the medication, if known, and if your cat is on this or any other medication currently:

    If your cat is inappropriately defecating, how would you describe the size of the stool:

    Small

    Normal

    Large

    If your cat is inappropriately defecating, have you noticed any of the following in your cat's stool:

    Yes

    No

     

    Abnormal Color (pale tan, pink, black, etc.)

    Blood

    Mucous

    If you have witnessed your cat not using the box, do you perceive that your cat is in any discomfort when urinating or defecating:

    Yes

    No

    If you answered 'yes' to the above question, please explain:

    If you have multiple cats, in your opinion, do your cats seem to get along well:

    Yes

    No


    Do they curl up and sleep together:

    Yes

    No


    Do they play together:

    Yes

    No


    Do they groom one another:

    Yes

    No


    Do they merely tolerate each other:

    Yes

    No


    To the best of your knowledge, are any of your cats ever “attacked” or “pounced upon” by one of your other cats just as he or she is getting into or out of the litter box:

    Yes

    No


    Have you noticed, recently or otherwise, any changes in the “cat dynamics” in your home? (Previously unchallenged dominant cat now being challenged? Two cats who previously got along well not getting along as well? Etc.):

    Is his or her behavior normal otherwise at this time:

    Yes

    No

    ...If no, describe:

    Have you noticed any changes in his or her appetite:

    Yes

    No


    How would you describe the change in appetite:

    Decreased Appetite

    Increased Appetite

    Have you noticed any changes in his or her weight:

    Yes

    No


    How would you describe the change in weight:

    Lost Weight

    Gained Weight


    Have you noticed any changes in his or her water intake:

    Yes

    No


    How would you describe the change in water intake:

    Decreased Water Intake

    Increased Water Intake


    Have you noticed any changes in the frequency of urination or volume of urine produced by the cat that is not using the box, or by any other cats in the home:

    Yes

    No

    If you answered ‘yes’ to the above question, please explain:

    What, if any changes have you noticed in your cat's coat:

    Does the cat that is known to not consistently use the litter box have any significant health history:

    Additional Comments:



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