QOL Assessment/How Do I Know When It's Time?

How Do I Know When it's Time?

Assessing Quality of Life for Your Companion Animal and Making End-of-Life Decisions
Survey Date*

MonthDayYear
Owner name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Pet name*
Breed*
Age*
Gender*
Weight*
in lbs
My pet does not want to play*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet does not respond to my presence or does not interact with me in the same way as before*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet does not enjoy the same activities as before*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is hiding*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet's demeanor/behavior is not the same as it was before*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet does not seem to enjoy life*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet has more bad days than good days*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is sleeping more than usual*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet seems dull and depressed*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet seems to be or is experiencing pain*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is panting (even while resting)*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is trembling or shaking*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is vomiting and/or seems nauseous*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is not eating well - (may only be eating treats or only if fed by hand)*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is not drinking well*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is losing weight*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is having diarrhea or constipation often*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is not urinating well*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is not moving normally*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is not as active as normal*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet does not move around as needed*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet needs my help to move around normally*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet is unable to keep self clean after soiling*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
My pet has coat that is greasy, matted or rough-looking*

1

2

3

4

5

1 is All the time/ Strongly Agree, 5 is Never/ Strongly Disagree
Total
How is my pet's overall health compared to the initial diagnosis/illness or if no specific diagnosis/illness how has my pet's overall health changed in the last year?*

WorseNo changeBetter
Total
Average
Average of Total:

1 Poor Quality of Life

2 Significantly Decreased Quality of Life

3 Mildly- Moderately Decreased Quality of Life

4 Slightly Decreased Quality of Life

5 Good Quality of Life
Much of this document has been adapted from the following sources: The HHHHHMM Quality of Life Scale: Dr. Alice Villalobos; Quality of Life Survey: Dr. David Vail; End-of-Life Values and Goals worksheet, University of Tennessee Veterinary Social Work Department

Jotform adapted by Kristine Haroldson, DVM, CRPM, FFCP
Should be Empty:

How Do I Know When it's Time?