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Feline House Soiling Questionnaire
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Owner's Name
Your answer
Pet's Name
Your answer
House Soiling Data Sheet
What percentage of the elimination incidents in the home are Urine_____% Stool_____%
Your answer
Does this pet urinate when petted?
Yes
No
Clear selection
When Excited?
Yes
No
Clear selection
When Scolded/Punished
Yes
No
Clear selection
Is there a preference for urinating inappropriately on
Upright Surfaces (walls, sides of furniture, drapes)?
Unlikely
1
2
3
4
5
6
7
8
9
10
Most likely
Clear selection
Horizontal Surfaces ( floors, tops of counters or furniture)?
Unlikely
1
2
3
4
5
6
7
8
9
10
Most likely
Clear selection
Is there a preference for secluded areas (closets, under furniture)?
Unlikely
1
2
3
4
5
6
7
8
9
10
Most likely
Clear selection
Do strays or pets from other households frequently visit or call outside windows, doors or in the yard?
Yes
No
Clear selection
Surface preference for inappropriate elimination:
Rugs
Clothing
Paper
Soil
Linoleum or other hard surfaces
No Preference
Other:
Clear selection
Age when housetrained? (If never housetrained, please mention)
Your answer
Method of Training
Your answer
Outcome of Training
Your answer
List the number of other pets in the home
House Mates
Cats - Female Intact
Your answer
Cats - Male Intact
Your answer
Cats - Female Spayed
Your answer
Cats - Male Neuter
Your answer
Dogs - Female Intact
Your answer
Dogs - Male Intact
Your answer
Dogs - Female Spayed
Your answer
Dogs - Male Neuter
Your answer
List any others
Your answer
Medical History
Has this pet ever had a cystitis (urinary bladder infection)?
Yes
No
Clear selection
Approximate Dates
Your answer
Does any straining or pain accompany urination?
Yes
No
Clear selection
Does any straining or pain accompany defecation?
Yes
No
Clear selection
Have you noticed blood in the urine?
Yes
No
Clear selection
Have you noticed blood in the stool?
Yes
No
Clear selection
Is there an increased frequency of urination?
Yes
No
Clear selection
Has there been an increase in water consumption?
Yes
No
Clear selection
Has there been an increase in the amount of urine voided?
Yes
No
Clear selection
Does the stool have an abnormal appearance?
Yes
No
Clear selection
Date of last urinalysis
MM
/
DD
/
YYYY
Results
Your answer
Litter Box Information
Has this pet ever eliminated consistently in the litter box?
Yes
No
Clear selection
When indoors, the pet defecates in the box ____% of the time
Your answer
When indoors, the pet urinates in the box ____% of the time
Option 1
Clear selection
How many litter boxes are available?
Your answer
How many are covered boxes?
Your answer
How often is the litter box cleaned?
Your answer
Type of litter used in the litter box
Standard Clay
Clumping
Other:
Clear selection
Brand of litter used
Your answer
How long has this brand been used?
Your answer
Where is the litter box(s) kept?
Your answer
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