Quality of Life Questionnaire
Ark Angel Vet | Dr Patrick
Pet’s Name
*
Pet’s Breed
*
Pet’s Age
*
in years.
Pet’s Weight
*
in kgs.
Your Regular Vet Hospital & Doctor?
My main concerns are:
Medical Diagnosis Details:
Current Medications:
Still Eating & Drinking Normally?
Yes
No
Does your pet have any of the following:
Vomiting
Diarrhoea
Coughing
Seizures
Frequent Urination
Increased Drinking
Panting
Restlessness
Weight loss and wasting
Distress
Blindness
Deafness
Loss of appetite
Not drinking
Blood in Urine
Blood in Motions
Other
Any signs of possible Dementia?
Not sleeping, restlessness, barking, staring into space, loss of house training, getting lost in the house.
Mobility?
Normal
Reduced Exercise Tolerance
Confined to Bed
Hindlimb Paralysis / Weakness
Movement with Pain & Stiffness
Other
Any Signs of Pain?
Yes
No
Unsure
Any Signs of Anxiety or Distress?
Yes
No
Unsure
Any Signs of Behavioural changes?
Yes
No
Aggression
Hyper-anxiety
not sure?
Any Signs of loss of urine or faeces control? (accidents in the house)
Yes
No
Any signs severe Dental Disease?
Smelly Breath
Bleeding Gums
Ulcerated Gums
Loose Teeth
Other
Would you like a call back by Dr Patrick?
Yes
No
I am ready to book an appointment.
Would you like to book an at-home euthanasia visit?
Yes
No
Not Sure
Your link to arranging a at-home Euthanasia appointment.
https://form.jotform.com/242771625378869
Your Name
*
First Name
Last Name
Phone Number
*
Postal Address
Email Address
Submit
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