* Name:

*Main Phone:

Alternate Phone:

* Email Address:

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:

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

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: