Quality of Life Scale

1

Your pet is engaging with you or acting the same from prior to diagnosis/illness.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

2

Your pet is still responsive to things around them (family, toys, etc).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

3

Your pet still expresses joy and interest.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

4

Your pet’s likes and dislikes have stayed the same.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

5

Your pet does not resist being pet or picked up.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

6

Your pet is not depressed, lonely, or bored.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

7

Your pet is not anxious, afraid, or aggressive/unsafe around others.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

8

Your pet is not in pain.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

9

Your pet’s pain can be successfully managed.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

10

Your pet does not have difficulty breathing.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

11

Supplemental oxygen isn’t necessary.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

12

Your pet is not panting, shaking, nauseous or vomiting, or losing weight.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

13

Your pet is eating enough and not refusing to eat.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

14

If necessary, hand-feeding or a feeding tube helps and is tolerated well.* This field is required.

Yes / Not applicable

Sometimes/Unsure

No, I disagree with the statement

15

You are able to blend food when necessary and find nutritious foods the pet enjoys.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

16

Your pet is drinking enough water (1oz/lb of body weight per day for dogs, 1.25oz/lb for cats).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

17

Your pet is not dehydrated (skin does not slowly retract after being pinched).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

18

Subcutaneous fluids are not necessary, or are tolerated well.* This field is required.

Yes / Not applicable

Sometimes/Unsure

No, I disagree with the statement

19

Your pet’s nighttime activities have not changed.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

20

Your pet is sleeping normally.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

21

You are able to provide routine activities that the pet enjoys (toys, walks, games).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

22

Your pet’s bed can be moved near family activities to minimize loneliness.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

23

Your pet is urinating properly (e.g. no excessive or reduced urination, or incontinence).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

24

Your pet is defecating properly (e.g. no diarrhea or incontinence).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

25

Your pet’s fur does not seem greasy, matted, or rough.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

26

Your pet does not have pressure sores.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

27

You are able to perform adequate grooming for your pet (brushing, cleaning after eliminations, keeping them free of parasites, cleaning wounds).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

28

Your pet can get up without assistance.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

29

Your pet does not need human or mechanical help (a cart, a rear support harness, etc.).* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

30

Your pet is not having seizures or stumbling.* This field is required.

Yes, I agree with the statement

Sometimes/Unsure

No, I disagree with the statement

31

Type a question

Total

32

Your Total Score: {totalscore}

41 - 60: Quality of life appears to be good or adequate. While your companion may be having some difficulties, a careful eye and consistent veterinary care and consultation should be all that is needed for now.

21 - 40: Quality of life appears to be waning. Your pet will almost certainly benefit from consulting a veterinary professional regarding his/her conditions in order to keep quality of life as high as possible.

0 - 20: Quality of life appears to be a serious concern. Changes at this stage often become more frequent and severe, and it is important to reach out for veterinary guidance in order to plan for end of life services, such as hospice care, or a pain-free passing.

33

Thank you for completing this Quality of Life scorecard for your companion.

You may either exit the form now, or click Submit to be directed to the Gentle Hands Cherished Paws registration form to schedule an appointment or consult. Submitting will also send us a copy of your answers, so that we can better understand your pet's condition.

We can also be contacted by phone or email:

Phone: (425) 507-5274

Email: contact@gentlehandscherishedpaws.com