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
2 digit month, 2 digit day, 4 digit year
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?
Total
Average
Average of Total:

1 Poor Quality of Life (>75% decreased QOL)

2 Significantly Decreased Quality of Life (75% decreased QOL)

3 Mildly- Moderately Decreased Quality of Life (50% decreased QOL)

4 Slightly Decreased Quality of Life (25% decreased QOL)

5 Good Quality of Life (100% QOL)
Would you like Paws of Serenity to reach out about scheduling a Quality of Life Consult or an At Home Euthanasia appointment?
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
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How Do I Know When it's Time?