QOL Questionnaire

1
Client Information* This field is required.
First Name
Last Name
Phone Number
Email
2
Pet Name* This field is required.First and Last Name
3
General HistoryWhat made you reach out to us? What are your priorities and goals for this consultation?
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Share with us your understanding of "what's going on" with your pet. What has been explained about their disease and what symptoms are you seeing?
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What treatment options or therapies have been offered to you for your pet's condition?Please include therapies you may not be interested in pursuing.
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What current medications and supplements is your pet receiving?Include dose (mg or tablet size) and frequency (timing) if possible.
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Nutritional Support
What is your pet's current diet?
What is your pet's estimated daily FOOD intake?
What is your pet's estimated daily WATER intake?
Are you having to hand feed/encourage eating?
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How easy is your pet to medicate? What struggles are you having administering their current medications?
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Are you comfortable with injections? Would you be open to learning how to administer injections to your pet? All injections would go under the skin like a vaccine. No vein or blood injections would be recommended.
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Are you open to utilizing alternative therapies?Acupuncture, laser, massage, herbal supplements
YESNO
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Future DiagnosticsOften repeat bloodwork, imaging and/or other tests can help to track patient status and diseases. What is your current interest in additional testing to monitor your pet's disease? (select all that apply)
I do NOT want further diagnostics and prefer to monitor my pet by outward symptoms alone.
I am open to in-home diagnostics ONLY (bloodwork, blood pressure, needle biopsies).
I am open to taking my pet to my primary care vet for imaging/tests (x-rays, ultrasound, etc)
I am open to taking my pet to a specialty center for advanced imaging/tests (CT, MRI etc)
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What are your "lines in the sand" with regards to stopping points in care?In other words, what do you NOT want your pet to experience. (ie: unable to stand, unwilling to eat, etc)
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Do you have any understandable financial considerations with managing your pet's ongoing care?Please note pet insurance provider if applicable.
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Travel and time apart:
How many hours a day is your pet left unattended?
Do you have any planned future travel? (Provide dates if possible)
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Please add any concerns or comments not addressed above? We look forward to meeting you and your pet and are grateful for this opportunity to be partners in their care! ☀️🐶😸
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