Name:___________________________



Cat Surrender History

Cat and Household Information

Cat’s Name: ______________________________ Sex: ○ Male ○ Female Age: Years _______ Months _______

How long have you had this cat? Years _______ Months ______

Is the cat spayed or neutered? ○ Yes ○ No

Where did you get this cat?

○ This shelter ○ Friend/relative ○ Newspaper/website ○ Found/stray ○ Breeder ○ Pet Store

○ Other shelter/rescue (Please write name) ___________________________________________________

○ Other (Please describe) ________________________________________________________________

Why are you surrendering this cat? Please check all that apply

○ Moving ○ Allergies ○ Found/stray ○ Not getting along with pets

○ Urinating outside of litter box

○ Behavior issues (Please describe) __________________________________________________________

○ Other (Please describe) ________________________________________________________________

Including yourself, how many people of the following ages live in your house? Please fill in the boxes.

|Age range (years)|Female |Male |

|0-3 | | |

|4-9 | | |

|10-17 | | |

|18-29 | | |

|30-59 | | |

|60+ | | |

What other animals did your cat live with?

○ No other animals in household ○ Dogs ○ Cats ○ Other (Please describe) ________________

Typical Behavior

If your cat has ever bitten a person, what were the circumstances? (Please check all that apply)

○ During play ○ While being pet ○ While being picked up or restrained ○ None of these

○Other (Please describe) ______________________________________________________________________________

Does your cat have any of the following behaviors? (Please check all that apply)

○Escaping outside ○Getting on counters/tables ○Chewing on electrical cords

○ Spraying urine ○Fighting with other cats/pets ○Scratches/bites people

○Scratching furniture ○Peeing around the house ○Meowing/vocalizing excessively

○Other (Please describe) ______________________________________________________________________________

How does your cat behave and/or interact with the following?

Adults |Young Children |Older Children |Strangers |Other cats |Dogs |At the vet office | |( Friendly |( Friendly |( Friendly |( Friendly |( Friendly |( Friendly |( Friendly | |( Playful |( Playful |( Playful |( Playful |( Playful |( Playful |( Playful | |( Cuddly |( Cuddly |( Cuddly |( Cuddly |( Cuddly |( Cuddly |( Cuddly | |( Tolerates |( Tolerates |( Tolerates |( Tolerates |( Tolerates |( Tolerates |( Tolerates | |( Hides |( Hides |( Hides |( Hides |( Hides |( Hides |( Hides | |( Aggressive |( Aggressive |( Aggressive |( Aggressive |( Aggressive |( Aggressive |( Aggressive | |( Not Applicable |( Never Been Around |( Never Been Around |( Never Been Around |( Never Been Around |( Never Been Around |( Never Been Around | |

If you did discipline the cat, what was it disciplined for? (Please check all that apply)

○ Litter box accidents ○ Eating plants ○ Getting on counters/tables ○ Scratching/biting people

○ Scratching furniture ○ Bothering other pets

○ Other (Please describe) _____________________________________________________________________________

What methods were used to discipline the cat? (Please check all that apply)

○ Verbal correction ○ Put the cat outside ○ Squirt bottle ○ Timeout in crate/carrier

○ Physical correction ○ Ignore the behavior ○ Did not discipline

○Other (Please describe) _____________________________________________________________________________

Is the cat afraid of any of the following? (Please check all that apply)

○ Women ○ Children ○ Brushing ○ Cat carriers

○ Men ○ Other animals ○ Going in the car ○ Going to the vet

○Other (Please describe) _____________________________________________________________________________

How does the cat behavior when it is afraid? (Please check all that apply)

○ Hides ○ Shakes ○ Bites ○ Other (Please describe) ________________________________________________

Exercise and Play

Does the cat use a scratching post?

○ Yes ○ No ○ No scratching post was provided

What type of surface does the cat prefer to scratch on? (Please check all that apply)

○ Carpet ○ Sisal fiber ○ Cardboard ○ Wood ○ Upholstery

○ Other (Please describe) ____________________________________________

What type of surface does the cat prefer to scratch on?

○ Horizontal/flat ○ Vertical/upright ○ Slanted/on an angle

What type of toys does the cat play with? (Please check all that apply)

○ Toy mice ○ String ○ Feathers ○ Balls ○ Lives prey (bugs, mice, birds, etc.)

○ Other (Please describe) ____________________________________________

What is the cat’s play style?

○ Average-with some nipping or scratching ○ Gentle-no scratching or nipping

○ Rough-scratches, bites but doesn’t break skin ○ Ambush/stalking style

○ Other (Please describe) ____________________________________________

What is the cat’s activity level?

○ Low energy ○ Average ○ Extremely active

Litter Box Set-Up

What type of litter box has the cat used?

○ Uncovered ○ Covered with a door ○ Covered with NO door ○ Did not use one

What type of litter is the cat used to?

○ Clay ○ Clumping ○ Pine ○ None ○ Other (Please describe) _____________________________________

Food/Diet

Is your cat currently on any medication or special diet?

○ Yes (Please describe) ________________________________________________________________________________

○ No

What type of food does this cat eat? Please check all that apply.

○ Dry (Please list brand) _____________________________ ○ Wet/canned (Please list brand) ________________________

How often/much is this cat fed?

○ Once daily ○Twice daily ○ Free Fed

Medical History

Name of veterinary clinic this cat has been to: __________________________________________________________

Person’s first and last name on the account at the vet’s office: ______________________________________________

When was the last time this cat was seen by a vet? _______________________________________________________

Please list any type of flea prevention this cat has received ________________________________________________

Date last flea prevention was given: ___________________________________________________________________

Is this cat declawed?

○ No ○ Yes-Front only ○ Yes-All 4 paws

Is this cat microchipped? ○ No ○ Yes (Please list name of company) ___________________________________________

Does this cat have any past or present medical conditions?

○ Yes (Please describe) ________________________________________________________________________________

○ No

Please feel free to tell us any additional helpful comments.

____________________________________________________________________________________________________________________________________________________________________________________________________

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Owner Name:

____________________________

Phone Number:

____________________________

Email:

____________________________

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