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Quality of Life Form

Client details

First name ^*

Last name ^*

Email ^*

Phone ^*

animal details

Animal Name ^*

Animal species ^*

Select Dog Cat Bird Guinea Pig Reptile Rabbit Horse Other

Animal breed ^*

Animal DoB or age ^*

Animal gender (e.g. male, female, unknown) ^*

Select Female Male Unknown

Desexed (Yes, No) ^*

Select Yes No

Patient weight ^*

Date of my pet's quality of life appointment:

Time of my pet's quality of life appointment: ^*

My pet was diagnosed with this disease/illness: ^*

I give my pet these medications or supplements: ^*

How is my pet's overall health compared to the initial diagnosis/illness? (Better, Worse, The same) ^*

Quality of Life Evaluation

Deciding to euthanize your companion animal may be one of the most difficult decisions you ever make. The quality of animals’ lives is defined by their overall physical and mental well-being, not just one aspect of their lives. The information from this form attempts to consider all aspects of your pet’s life and may provide you and your veterinarian help to better visualize the general well-being of your pet. However, in some cases, even one choice on the chart (for example: pain) may indicate a poor quality of life, even if many of the other items are still positive while other symptoms on the list may be expected side effects of the treatments that your pet is undergoing. It is important to discuss these symptoms and side effects with your veterinarian.

Please evaluate as accurately as possible: Strongly Agree (All the Time) (Severe) - 5 Agree (Most of the Time) (Significant) - 4 Neutral (Sometimes) (Mild) - 3 Disagree (Occasionally) (Slight) - 2 Strongly Disagree (Never) (None) - 1

Does not want to play

Does not respond to my presence or does not interact with me in the same way as before

Does not enjoy the same activities as before

Is hiding

Demeanor/behavior is not the same as it was prior to diagnosis/illness

Does not seem to enjoy life

Has more bad days than good days

Is sleeping more than usual

Seems dull and depressed

Seems to be or is experiencing pain

Is panting (even while resting)

Is trembling or shaking

Is vomiting and/or seems nauseous

Is not eating well - (may only be eating treats or only if fed by hand)

Is not drinking well

Is losing weight

Is having diarrhea often

Is urinating inappropriately (on self, in home)

Is not moving normally

Is not as active as normal

Does not want to move around

Needs my help to move around normally

Is unable to keep self clean after soiling

Has coat that is greasy, matted, or roughlooking

Has trouble seeing or hearing

Has bleeding or uncomfortable wounds or masses

Additional Questions

In addition to the above chart, are there other specific concerns your pet is having that has lead you to consider euthanasia?

If there are any diagnostic options available to help in the treatment of your pet, would you like the vet to discuss them with you?

Yes

No

If there are any reasonable or effective treatment options available to your pet, would you like the vet to discuss them with you?

Yes

No

Are you considering euthanasia for your pet?

Yes - I am ready to euthanize my pet and understand that I must complete the euthanasia and cremation form found in the same email as the link to this form.

No - I am not ready to euthanize my pet at this time and wish to cancel my appointment.

Unsure - Would like to discuss further diagnostic and/or treatment options with the vet. I will still complete the euthanasia and cremation form found in the same email as the link to this form.

Please sign here^*

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AMENDMENT

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I, the undersigned, acknowledge that I have read and understood this amendment, which has been fully explained to me, and that it modifies the original consent form to which it is attached. I confirm that all information provided is accurate and that I consent to the changes outlined in this amendment. I understand that this amendment is part of the original consent form.

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