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.
____________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
-----------------------
Owner Name:
____________________________
Phone Number:
____________________________
Email:
____________________________
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