Quality of Life Assessment Tool

Quality of Life Assessment Tool

0=No/Does not describe my pet. 1=Somewhat agree. 2=Yes/Describes my pet
Has you pet experienced episodes of panting or any changes in breathing?*
Has your pet’s eating habits changed? Do they require hand feeding, syringe feeding and/or tube feeding?*
Would you consider your pet’s hydration level adequate? (Do you find yourself filling their water bowl as per usual)? Do they require subcutaneous fluids?*
Does your pet require assistance getting up and/or getting around?*
Has your pet shown any changes in their interaction with family members? For example: not wanting to be around family as much as they used to. Hiding or seeming aloof ?*
Does your pet resist or become increasingly distressed when bathing or gentle cleansing in order to maintain adequate hygiene? *
Has your pet shown signs of aggression, irritation or avoidance of household pets (if applicable) and/or family member(s). *
Have you noticed any changes in your pet’s interest in normal activities (play, walks, toys, affection)*
Does your pet seem anxious?*
Do they spend most of their waking hours pacing?*
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Pet's Name*
Breed*
Approximate Age*
Has your pet been seen by their primary veterinarian within the last year?*

YesNoI do not have a primary veterinarian for my pet
I understand that this assessment is not a verified scale in determining my pet's quality of life. This assessment is a guide meant for pet parents to utilize in order to determine which House Call Vet RVA's End-of-Life care services are the best fit for my pet. This tool is neither a diagnostic nor acts as a prognostic indicator for my pet, their illness, disease or life stage.
Calculation
Would you like a member of our team to reach out to you?*

YesNo
Interpreting your results
0-6: Quality of life is most likely adequate. We recommend guidance from your primary veterinarian at this point.
7-13: Quality of Life is questionable. Based on your pet's assessment, we recommend a Tele-Advice Consultation.
14-20: Quality of life is a concern. We strongly recommend veterinary guidance at this point. Changes in your pet will likely progress and worsen. A veterinarian and their team will help you to better understand the disease and/or illness your pet is experiencing help educate and guide you on pet hospice or humane euthanasia. Our Tele-Advice Consultation Service and/or In Home Consultation are both options we recommend a this time.
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