Litterbox History Form Elimination Problem History FormToday's Date* MM slash DD slash YYYY Owner’s Name*Home Phone*Cell Phone*E-mail address* Address* Street Address City State / Province / Region ZIP / Postal Code YOUR PETPet’s nameWhat percentage of the elimination incidents in the home areUrine%Stool%Is there a preference for urinating inappropriately on: Upright surfaces(walls, sides of furniture, drapes) Yes No Upright%Horizontal surfaces(floor, top of counters or furniture) Yes No Horizontal%Is there a preference for secluded areas? (closets, under furniture, etc.)? Yes No Do strays or pets from other households frequently visit or call outside win- Yes No Surface preference for inappropriate elimination: Rugs Clothing Paper Soil Linoleum Or Other Hard Surfaces Other No Preference OtherMedical HistoryHas this pet ever had cystitis (urinary bladder infection)? Yes No Approximate dates MM slash DD slash YYYY Does any straining or pain accompany urination/defecation? Yes No Approximate dates MM slash DD slash YYYY Have you noticed blood in the urine/stool (specify)? Yes No Approximate dates MM slash DD slash YYYY Is there an increased frequency of urination/defecation (specify)? Yes No Approximate dates MM slash DD slash YYYY Has there been an increase in water consumption? Yes No Approximate dates MM slash DD slash YYYY Has there been an increase in the amount of urine voided? Yes No Approximate dates MM slash DD slash YYYY Does the stool have an abnormal appearance? Yes No Approximate dates MM slash DD slash YYYY Litterbox Information (cats)How many cats are in the home?Has this pet ever eliminated consistently in the litterbox? Yes No When indoors The pet defecates in the box Never defecates in the box The pet defecates in the box ____ % of the timeWhen indoors The pet urinates in the box Never urinates in the box The pet urinates in the box ____ % of the timeHow many litter boxes are available?How many are covered boxes?Size/Dimensions of the boxesHow often is the litterbox cleaned?Type of litter used in the litterbox Standard clay Clumping Other OtherBrand of litter usedHow long has this brand been used?Where is the litterbox(es) kept?Please diagram your house below. Indicate areas of inappropriate urination, defecation, urine spraying, litterbox positions (cats) and feeding areasMax. file size: 256 MB.EmailThis field is for validation purposes and should be left unchanged.
