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

Email* This field is required.

example@example.com

4

Owner's Address

Street Address

Street Address Line 2

City

State

Zip Code

Country

5

Pet's name* This field is required.

6

Gender* This field is required.

7

Species* This field is required.

8

Breed* This field is required.

9

Age* This field is required.

10

Weight* This field is required.

11

PET INFO

Pet's name

Species ( cat/dog)

Age

12

Regular Veterinary Clinic* This field is required.

13

How did you hear about us?* This field is required.

14

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

15

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)

16

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)

17

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)

18

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)

19

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)

20

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)

21

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)

22

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)

23

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)

24

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)

25

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)

26

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)

27

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)

28

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)

29

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)

30

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)

31

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)

32

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)

33

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)

34

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)

35

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)

36

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)

37

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)

38

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)

39

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

Worse

Same

Better

41

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

42

Are you interested in scheduling an End of Life Visit?

YESNO

43

Thank you for your interest in scheduling an appointment. Once you submit this form, you’ll be redirected to our Request an Appointment form to complete your request.