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Urinary Tract Questionnaire
First Name
Last Name
E-mail
My pet is
urinating normally
urinating frequently
straining to urinate
leaking urine
When did you first notice these symptoms?
today
yesterday
more than two days ago
Is there blood in the urine?
Yes
No
Is your pet’s activity level
normal
lethargic
hyperactive
What do you feed your pet?
Is your pet’s water consumption
the same
increased
decreased
Do you find your feline pet in the litter box
often
for long periods of time
normally
Have you changed brands of cat litter recently?
Yes
No
Have you change type of litter pan or its location recently?
Yes
No
Is your pet urinating in inappropriate places?
Yes
No
Have there been any changes in your pet’s normal environment recently (like a new family member, new pet, loss of a companion or family member, move to a new house, etc.?
Yes
No
Has your pet ever been treated for these or similar symptoms before?
Yes
No
Is your pet on any medications?
Yes
No
Does your pet have any other symptoms not addressed on this form?
Yes
No