Indicates required field Please select the type of pet Please select the type of pet - Select -DogCat Dog Cat General Information Pet name Age Birthdate, if known Sex - Select -MaleFemale Spayed / neutered? Yes No When was she last in heat? Has she ever had a litter? Yes No When did she have a litter? If multiple, please list all known dates Reason for surrender Background How long have you owned them? Where did you obtain them? Who is their veterinarian? When was their last vet visit? Any health issues / concerns? Are they currently taking any medications? Yes No Please list any current medications and dosages, if known. What type(s) of food do you feed? Select all that apply Dry Wet Homemade What brands, flavors, or ingredients? Are there other pets in the house? Yes No How many other pets? What type(s) of other pets? Are there children in the house? Yes No How many children? What age(s)? Where do they stay when you are asleep? Where do they stay when you are not home? Are they house-trained? Yes No Do they ever go outside? Yes No Behavior How do they react to children? How do they react to other pets? How do they react to being home alone? What makes them angry or reactive? What are they afraid of? How do they react when company comes over? How do they react to nail clipping? How do they react to brushing, bathing, or grooming? How do they react to travel? i.e. in a carrier, car rides How do they react to vet appointments? Have they ever bitten or scratched? Yes No Bite / Scratch Incident Information When did the incident happen? Who was bitten or scratched? Where on the body was the injury? Did the bite or scratch break skin or cause bleeding? Yes No Was medical attention required? Yes No What happened leading up to the incident? What do you think caused them to bite or scratch? How do they react to being held / picked up? Do they use a scratching post? Yes No What do they use to scratch? Do they reliably use a litter box? Yes No Litter Box Behavior Select all that apply They urinate outside of the litter box They defecate outside of the litter box How often do they not use the litter box? Where do they go to the bathroom instead? Has a veterinarian determined a medical cause for the behavior? Yes No What did the veterinarian determine? Were there any changes in the home prior to the behavior? Yes No What were the changes? Have you tried to correct the behavior? Yes No What have you tried? Personality Which traits best describe them? Select all that apply Affectionate Calm Cautious Friendly Hyper Independent Jumpy Knows tricks Mouthy Obedient Outgoing Playful Protective Quiet Rough Smart Temperamental Timid Vocal Describe their energy level Favorite toys / activities? Additional information
