Quality of Life Score

Quality of Life Score

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Date*

MonthDayYear
Date
Client Information
Client's Name*

First NameLast Name
Client's Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Pet Information
Pet's Name*
Species*

CanineFeline
Breed*
Age/Date of Birth*
Sex*

Female, IntactFemale, SpayedMale, IntactMale, Neutered
Life Activities

Think of your pet in their prime. Using that as a reference point, how would you score each category (with 0=poor and 100 = excellent)?
Mental Status (Depression)*
Activity*
Appetite*
Defecation (difficulty or leakage)*
Urination (difficulty or leakage)*
Overall Happiness*
SUBTOTAL OF LIFE ACTIVITY SCORE*
Pain Score (0-100)*
0= Pain free, 100=Extreme pain
QUALITY OF LIFE SCORE*
Fill in each category to get your pet's Quality of Life Score Recommendation.
Quality of Life = Excellent!

Medical intervention is likely not necessary at this time, however if you do have some concerns, please click below to request a consultation.
Quality of Life = Good!

Your pet is likely in good health the majority of the time, but has the occasional flare up with their disease. Periodic visits every 1-3 months are recommended to properly monitor and treat your pet's condition. Please click below to request an appointment.
Quality of Life = Moderate.

Your pet may be in the early stages of their disease process, have a new or worsening condition, or require a modification in their current maintenance plan. Initially, visits every 1-3 weeks are recommended for specific and targeted testing and/or treatment. Please click below to request an appointment.
Quality of Life = Poor

Your pet's condition is likely very severe or worsening rapidly. We strongly recommend hospitalization at a 24/7 veterinary facility and/or visits every 2-3 days to closely reasses and treat their disease. Without care, your pet's condition will become critical and/or fatal. Please click below to request an appointment.
Quality of Life = Dismal

Unfortunately, your pet may be in the end stages of their disease process where treatment is most likely not going to be curative or effective. We strongly recommend discussing your pet's condition with a veterinarian to decide whether to proceed with hospice care or humane euthanasia. Please click below to request an appointment
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Quality of Life Score

Client Information

Pet Information

Life Activities

Quality of Life = Excellent!

Quality of Life = Good!

Quality of Life = Moderate.

Quality of Life = Poor

Quality of Life = Dismal