House Soiling Survey



Pet Family

* Your Name

Spouse, Partner or Roommate

Children and ages

* Email

* Phone

Cat Info

* Cat's Name

* Cat's Age

* Cat's Sex

* Cat's Breed

Pet Interaction


* How does your cat interact with family members?
   Friendly
   Aggressive
   Nervous
   Avoids Contact

* Who is your cat's favorite person?

* How does your cat interact with strangers?
   Friendly
   Aggressive
   Nervous
   Avoids Contact

Name and age of other cats. Label the order they arrived in the house

Other pets (species, breed and ages)

If you have other cats or pets in the household, have you seen your cat responding to them in any of the following ways?
   Playing together
   Sleeping together
   Mutual grooming
   Being Agressive (eg, hissing, growling, swiping)
   Running away

Please describe interaction

How do you think your pets get along?


Outdoor Interaction


Does your cat go outside?
   Yes
   No
   Occasionally sneaks out
   Goes outside supervised
   Goes outside unsupervised
   Has pen our outside enclosure

If you have a cat door or flap, please describe

Can your cat see other animals from inside your home?
If yes, describe (ie cats, birds at feeder, etc)


Food


Canned Food and Type?

Dry Food and Type?

Have you changed the food recently?


Litter


How many litter boxes are in your home?

Types of Litter Boxes
   Open
   Hooded or Covered
   Automatic

Liners used?

Deodorizers used?

Average size in cm or inches?

Who scoops the litter box?

How often to you scoop the litter box?

Type of litter used?
   Fine grain (clumping)
   Wood or paper-based pellets
   Corn or wheat based
   Non-clumping clay
   Scented
   Garden Soil
   Coarse Granules
   Silica granules or beads

Other type of litter (describe)

How often do you wash the litter box and what cleaning products do you use?

House Soiling


If your cat urinates when house-soiling, how would you describe the urine?
   Normal
   Strong Odor
   Passed more/less frequently than usual
   Large volume
   Sticky Consistency
   Small Volume
   Bloody

If your cat deficates when house-soiling, how would you describe the stools?
   Normal
   Blood / Mucas
   Small and Hard
   Formed in part, then softer
   Soft and Watery

Deficate description other

How long has the house soiling been occuring

Do you remember the first incident? If so, describe

What kind of surface is targeted?
   Carpet
   Tile
   Wood
   Bedding / Clothing
   Vinyl
   Bath / Shower / Sink / Basin
   Particular family member

Family member target

Other target surface

Is the cat targeting vertical surfaces with urine? If so, what volume is being passed?

How often is the house soiling occurring?

How has the frequency changed since the problem started?
   Increased
   Decreased
   Remained the same
   Do not know

Have there been any changes recently (or around when the house-soiling started) ?
   Moved to new home
   New baby or pet
   Absence of family member or pet

Other changes (including work / school schedule changes, please provide details?

Please detail what you have been doing to clean the soiled areas

Have you used any physical punishment in response to the house-soiling? (eg rubbing nose in the urine or stool, spanking, water pistol, shouting, confinement) Please describe

Is your cat easy to medicate?
   Yes
   No

What are your preferred formulations for any medications
   Pills
   Oral Liquids
   Medication in food
   Transdermal gel (when available)

Have you used any physical punishment in response to the house-soiling? (eg rubbing nose in the urine or stool, spanking, water pistol, shouting, confinement) Please describe

Drawing of House

Please either attach a drawing or bring one to the appointment.
This is very important. Mark all items listed below on the house floor
plan we can get a feeling for the environment where your cat lives,
It does not have to be to perfect scale

a = litter box locations
b = House-soiling locations
c = Windows and doors
d = Scratching post locations
e = Food and water bowl locations
f = Cat door or flaps

Acceptable file types are docx, pdf, jpg, jpeg, gif, png