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Elimination Disorders Form
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" indicates required fields
Your Name
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First
Last
Phone
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Email
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Patient Name
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Date
MM slash DD slash YYYY
Elimination Disorders
Is the cat urinating outside the box?
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Yes
No
If so, where?
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How long has he/she been going there?
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Is the cat defecating outside the box?
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Yes
No
If so, where?
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How long has he/she been going there?
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How many litter boxes are there?
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How many of the litter boxes are covered?
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Where are the boxes?
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What kind of litter do you use? (Check all that apply) Please also list brand and if the litter is scented or unscented.
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Scoopable (sand-like that clumps when wet)
Clay (larger pieces that do not clump when wet)
Other (please list)
List the brand and is it scented or unscented.
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How often do you scoop out the litter box?
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How often is the box completely emptied and fresh litter put in?
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Are liners used?
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Yes
No
Are they scented?
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Yes
No
How deep is the litter in each of the boxes? (Approximate inches)
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Are deodorants such as baking soda used in the box?
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Yes
No
If so, describe
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How many cats in the household are using these boxes?
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What does the cat do in the litter box: does he/she go in and out several times before voiding, does he/she dig in or outside the box?
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Have you changed types of litter being used in the past six months?
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Yes
No
If so, describe
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Have you changed brands of litter in the past six months?
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Yes
No
If so, describe
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Have you seen the cat going outside the box?
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Yes
No
Please describe what he/she is doing?
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Have there been any changes to the household in the past few months?
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Yes
No
Please describe what he/she is doing?
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How many cats are in the household?
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How many dogs are in the household?
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Is the cat acting aggressive to other members of the house?
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Yes
No
Is the cat acting aggressive to other pets in the house?
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Yes
No
If your cat is acting aggressive, please describe the behavior below:
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Do you have any other behavioral concerns about your cat?
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Yes
No
Please describe below:
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Email
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