PALS Cat history Form

If you prefer a printable form please download the (pdf) or word document. Then mail or fax it to PALS. Thank you.

1. Date:

2. Owner/Handler:

First name
Last name
Phone #
EMail

3. Cat's Bio:

Name
Date of birth

4. Breed of Cat: (or species, if not a cat)

5. Gender:

Female
Female - Spayed
Male
Male - Neutered

6. Age of cat when acquired?

7. How did you acquire your cat?

8. If the cat was NOT a kitten, what do you know of its history?

9. What type of collar do you most commonly use?

10. Is cat used to walking on a leash?

Yes No

11. Is cat fully house trained?

Yes No

12.What is your cat's reaction to: (Check ALL that apply)

a) Other Cats

b) Dogs

c) Children

Playful	Chases	Accepts calmly	Nervous
Afraid	Aggressive	No experience

d) Vet's Office

13. Any other unusual reactions (i.e. men, uniforms, hats, people with canes)?

14. Has your cat ever scratched or bitten anyone?

Yes No

If yes, please provide detailed explanation:

15. Which veterinary clinic do you use?

16. Currently rabies vaccinations are mandatory for all pets accepted into our program. Did you provide this protection for your cat?

Yes No, but I will, so that my application can be processed

17. Has your cat had surgery in the last 6 months?

Yes No

If yes, please provide details:

18. Is your cat on any medication?

Yes No

If yes, please provide details:

19. Has your cat ever been in a fight with another animal or had any experience which you may consider traumatic?

20. How does your cat fair riding in the car?

bad poor average fair good

21. List things your cat does NOT like:

22. Please detail any behavioral problems you have encountered with your cat:

Once you and your pet are accepted into the pet visitation program, you will be assigned to a team of volunteers visiting a specific facility on the SAME day or days of week each month. The following questions will help us find a suitable placement:

23. Do you and your pet have a strong preference for visiting:

Children Elderly No Preference

If you have a preference, please tell us why:

24. Which area of the city do you prefer?

NW SW NE SE No Preference

25. Days you are available: (No Pet Visits on Fridays)

Monday Tuesday Wednesday Thursday Saturday

26. Times you are available:

Morning Afternoon Evenings

27. Is there any day/time you are absolutely NOT available?

28. Is there any additional information you would like to add?