Animal Surrender Profile | Humane Society of Missouri

The following animal profile will give us a better understanding of your pet's behavior in certain situations. By providing this information, you help us get to know your pet so we understand their needs. This can help us make the best family placement.

Please be open and honest with your answers and provide as much information as possible. If you require more space for answers, we can discuss additional details once we contact you.

This profile does not guarantee that your pet will go into the adoption program.

You must complete the profile form to request a surrender appointment.

"*" indicates required fields

Chose your Humane Society of Missouri Location*

HSMO Macklind - St. Louis City

HSMO Maryland Heights

Do you own this pet?*

Yes

Please call the Humane Society of Missouri St. Louis City before completing this form: 314-951-1562

Please call the Humane Society of Missouri Maryland Heights before completing this form: 314-951-1588

Basic Information

Pet's Name*

This animal is a*

please note; this form is not for farm or other large animals; ie ducks, chickens, horses, pigs.

Dog

Cat

Small Mammal (ie, guinea pig, gerbil, hamster, ferret, rabbit, etc.)

Small bird (ie; parakeet, parrot,)

Reptile or Amphibian

Breed*

Age*

Approximate weight*

0-20 lbs

21-40 lbs

41-75 lbs

over 75 lbs

Sex*

Male

Female

Unknown

Has this pet been spayed/neutered?*

Yes

Not Sure

List approximate date

Is this pet microchipped?*

Yes

Unknown

Microchip number

If known

Did you acquire this pet from the Humane Society of Missouri*

Yes

Where did you acquire this pet?*

Do you know this animal's origin?*

Wild-caught

Captive bred

Hand raised

Mother reared in captivity

Unknown

Why are you surrendering this pet?*

How long has this pet lived with you?*

How many owners has this pet had before you?*

Where does this pet spend most of its time?*

Inside Only

Outside Only

Inside and Outside

Explain where this pet spends it's time*

On average, how many hours a day does this pet spend alone?

Where do you leave this pet when no one is home?*

Free Indoors

Outdoors

Confined to a room

In a crate

Other

Explain where you leave the pet when you are not home

Where does this pet sleep?

Is this pet allowed on the furniture?*

Yes

Is this pet house / litterbox trained?*

Yes

What kind of litter do you use?*

Clumping

Clay

Crystals

Other

Litter type

Does this pet have accidents in the house?*

Yes

How often does it have accidents in the house?*

Daily

Several times a week

Weekly

Rarely

What kind of accidents does your cat leave?*

Urine

Stool

Both

How long have litterbox problems been occurring?*

Where do the accidents occur?*

Next to the litterbox

In the same room as the litterbox

In 1 or 2 specific places in the house and nowhere else

In more than 1 or 2 places in the house

On furniture

In the laundry

Other

Specify where the accidents occur*

Has a veterinarian diagnosed a medical cause for the accidents?*

Yes

What was the diagnosis?*

Did any major changes occur around the time that your cat started having litterbox issues? (i.e. new baby, moving, changed location of litterbox, etc)*

Yes

Please explain the changes related to the litterbox issues

How many cats live in the home (including this one)?

How many litterboxes do you have in the home?*

Where are the litterboxes located?*

How many floors in your home?*

Are there litterboxes on each floor?*

Yes

How often do the boxes get scooped or emptied?*

Explain how often litterbox is changed?*

What type of food does this pet eat?*

check all that apply

Pellets

Fresh food, fruits/veggies

Hay

Seed

Other

Pellet Brand*

Seed Brand*

Favorite fresh foods*

Please list other foods this pet eats*

Please describe what foods your reptile / amphibian eats and how you prepare it*

How often do you feed your pet?*

Free access

Twice daily

Once daily

Every other day

Twice a week

Once a week

Every 2 weeks

Less frequently than 2 weeks

What type of enclosure does this pet use?*

What type of bedding do you use?*

Do you provide heat lamps?*

Yes

Do you provide another heat source*

Yes

Please list other heat sources provided*

Does this pet escape its enclosure?*

Yes

How often does it escape?*

How often do you take this pet out of its enclosure?*

How much time does it spend outside it's enclosure?*

0-1 hours

1-4 hours

4-8 hours

8-12 hours

More than 12 hours

Does this pet spend time outside?*

Yes

Describe where it goes and how long it stays outside*

History with People

While you've owned this pet, have children (under 18) lived in or regularly visited your home?*

Yes

List ages of children

How did the pet interact with the children?*

check all that apply

Has this pet ever bitten a person?*

Yes

How many times has the pet bitten?

When was the most recent bite?*

Less than 11 days ago

12 days to one month

In the last 3 months

In the last year

More than a year ago

The most recent bite*

Drew blood

Left a mark or bruise

Did not leave a mark

Who was bitten in the most recent incident?*

Member of the family

Guest

Stranger

Please describe what happened*

Are there any situations or items that cause this dog to growl, snarl, bark, lunge, snap or otherwise act aggressively toward people?*

Yes

What types of situations?*

check all that apply

Describe the situation*

History with Animals

Does this pet live with dogs?*

Yes

How many dogs does pet live with?*

How do they interact with dogs?*

check all that apply

Played well together

Pets sleep together

Pet avoids other animals

Growl/hiss/fight other pets

Does this pet live with cats?*

Yes

How many cats does this pet live with?*

How do they interact with cats?*

check all that apply

Played well together

Pets sleep together

Pet avoids other animals

Growl/hiss/fight other pets

Does this pet live with small animals?*

Yes

What species?*

Has it been housed in the same cage with other animals of the same species?*

Yes

Was its cage mate the opposite sex?*

Yes

Did it get along with the animals it was housed with?*

Yes

How do they interact with small animals?*

check all that apply

Played well together

Pets sleep together

Pet avoids other animals

Growl/hiss/fight other pets

Has this dog ever attacked/killed another animal?*

Yes

List type of animal, severity of bite, when and why it occurred

Are there any situations or items that cause this dog to growl, snarl, bark, lunge, snap or otherwise act aggressively toward other dogs?*

Yes

Check all that apply

List other

Describe the severity of the dog's aggressive reaction

Has this dog ever visited homes with other dogs or dog parks?*

Yes

How do they do on visits / dog parks?

Are there any dog friends this dog plays with on a regular basis?*

Yes

How do they do playing with dog friends?*

Medical History

Does this pet have any special medical or dietary needs?*

special diets, ongoing medicine, etc.

Yes

Please explain*

Does this pet have any previous health issues or injuries?*

surgeries, seizures, old fractures, allergies, etc.

Yes

Please explain*

Has your dog been tested for heartworms in the past 6 months?*

Yes

What were the results?*

Positive (has heartworms)

Negative (does not have heartworms)

Is this cat declawed?*

Front Only

Front & Back

Has this cat ever tested positive for FIV?*

Yes

Has this cat ever tested positive for Feline Leukemia?*

Yes

Has the pet ever been diagnosed or treated for the following?

Check all that apply

Please list other diagnoses and treatments*

Please explain previous illnesses*

Pet Personality

Share three things you like about this pet and want others to know*

Does this pet like to be handled?*

Yes

Are there places on its body it does not like to be touched?*

Is this pet afraid of anything?*

Yes

Please list the pet's fears*

How does the pet react when afraid?*

Runs away

Flinches and cowers

Growls/hisses or attacks

Other

Please describe the pet's fear reaction*

check all that apply

What are this pet's favorite toys/games?*

Does this pet know any commands and/or tricks?*

Yes

Please list the commands/tricks*

Have you taken this dog to a trainer or puppy classes?*

Yes

Check all of the words that describe this pet's personality*

check all that apply

Calm

Friendly

Energetic

Independent

Playful

Fearful/shy

Anxious

Confident

Aggressive

What one thing would you like to change about this pet?*

What else would you like to share about this pet?

When left alone, does this dog do any of the following?*

check all that apply

Destroy household Items

Urinate/defecate

Bark constantly

Cry/whine

Howl constantly

Break out of crate/kennel

Chew/scratch under or around doors or windows

None of these

How frequently does this behavior occur?*

How long after you leave does your dog wait before doing these things?*

My dog does these things immediately and for an extended time

My dog does these things immediately but stops after a little while

My dog waits 1-2 hours before doing these things

My dog waits 2-4 hours before doing these things

My dog waits 4-6 hours before doing these things

Does this dog enjoy car rides?*

Yes

Does this dog get car sick?*

Yes

Does this dog escape from the yard or house?*

Yes

How often does dog escape?*

Daily

Weekly

Monthly

Several times a year

How does the dog escape?*

Is your yard fenced?*

Yes

What type of fence and how tall is it?

Select the level of exercise that best describes what this dog requires/prefers*

Low: Spends most of the day sleeping or resting, wants occasional walks or playtimes

Mild: Likes to play for a while or take a few short walks and then will rest or relax

Moderate: Needs multiple medium-long walks each day, or longer amounts of playtime/fetch

High: Needs regular jogs/runs or sports activities like frisbee/agility/fly ball

Describe this cat's personality*

check all that apply

Laid back and relaxed, not bothered by activity

Mischievous, always into something

Loves to be in your lap or seeks petting often

Independent, seldom seeks attention

Hides, seldom seen

Playful

Does not want to be held or picked up

Describe this cat's activity level*

check all that apply

Low: Spends most of the day sleeping, want occasional petting or playtime, is quiet during night

Moderate: Likes to play for short periods then rest or relax around family, is quiet during night

High: Seeks human attention often, very active overnight

Your Information

Your name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

XXX-XXX-XXXX

Signature

By signing below, I certify that the information I am about to provide is accurate and truthful to the best of my knowledge.*

Please type your full name

Date*