QOL Assessment Form

1

Owner's Name* This field is required.

First Name

Last Name

2

Owner's Phone Number* This field is required.

Please enter a valid phone number.

3

Owner's Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

4

PET INFO

Pet's name

Species ( cat/dog)

Age

5

Presenting Condition(s)* This field is required.what illness/illnesses does your pet suffer from

6

My pet does not want to play* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

7

My pet does not respond to my presence or does not interact with me in the same way as before * This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

8

My pet does not enjoy the same activities as before* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

9

My pet is hiding* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

10

My pets demeanor/behavior is not the same as it was prior to diagnosis/illness* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

11

My pet does not seem to ejoy life* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

12

My pet has more bad days than good days* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

13

My pet is sleeping more than usual* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

14

My pet seems dull and depressed* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

15

My pet seems to be or is experiencing pain* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

16

My pet is panting (even while resting)* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

17

My pet is trembling or shaking* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

18

My pet is vomiting and/or seems nauseous* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

19

My pet is not eating well - (may only be eating treats or only if fed by hand)* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

20

My pet is not drinking well* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

21

My pet is losing weight* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

22

My pet is having diarrhea often* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

23

My pet is not urinating well* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

24

My pet is not moving normally* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

25

My pet is not as active as normal* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

26

My pet does not move around as needed* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

27

My pet needs my help to move around normally* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

28

My pet is unable to keep self clean after soiling* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

29

My pet has coat that is greasy, matted or rough looking* This field is required.

Strongly Disagree ( never/none)

Disagree (occasionally/slightly)

Neutral (sometimes/mild)

Agree (most of the time/significant)

Strongly Agree (all the time/severe)

30

How is my pet's overall health compared to the initial diagnosis/illness* This field is required.

Worse

Same

Better

32

Are you interested in a virtual or an in home QOL consultation with one of our doctors?* This field is required.QOL ( quality of life)

YESNO

33

Are you interested in scheduling an End of Life Visit?

YESNO

34

Please fill out the New Client form by clicking here: REQUST AN APPOINTMENT

Once we have confirmed that your address is within our service area we will contact you and you will be emailed a pre-filled Consent form. There you will choose your cremation option and sign. We will need the completed consent form in order to complete your booking.

* Please note these forms do not obligate you to anything