Please Note: We will be closed on Wednesday, December 25th and Thursday, December 26th in observance of Christmas.

Quality of Life

SURVEY

Time is nothing if it’s spent suffering. We want quality time over quantity of time – ALWAYS. Your entire household should participate in evaluating your pet’s QOL. This is an emotional situation – you can’t expect to be accurate or unbiased. Get help from your friends, family and veterinary team!

Basic Quality of Life Scale:

1. We want them eating
2. We don’t want them vomiting
3. We want them clean and dry
4. We don’t want them in pain
5. We don’t want them anxious or afraid
6. They need to still love and hate all the things they usually love and hate
7. They need to have more good days than bad.

If your pet is missing any of these, we need to act – either to relieve their discomfort or to help them pass away. Remember, there is always something we can do!

Quality of Life Evaluation Survey

Please complete our extensive QOL evaluation below. It is helpful to have all members of the household participate while completing the form.

What county do you live in? *

Hillsborough
Manatee
Pasco
Pinellas
Other

If other, please specify *

Pet's Name *

Your Name *

First

Last

Phone *

Do you text at this number? *

E-mail *

Is your pet a *

Cat
Dog
Rabbit
Other

What species is your pet?

What city do you live in? *

What is your zip code? *

Please select any of the following signs of pain you have seen in your pet. Please note that pets rarely cry when they are in pain.

Hiding
Limping
Crying
Jumping less or less high
Running less or less distance
Walking less or less distance
Dislikes being touched in certain places
Walks stiffly
Difficulty getting up
Difficulty lying down
Difficulty turning
Difficulty climbing up stairs
Difficulty going down stairs
Difficulty getting onto furniture
Difficulty getting off furniture
Restlessness
Pacing
Panting when at rest in a cool area
Twitches skin when touched
Sleeping in unusual places
Sleeping in unusual positions
Obsessively licking certain parts of the body
Tense belly
Whining
Turning head at you or nipping/biting/ growling when you touch certain areas or try to lift them
Crying out (especially when picked up)
No, my pet does not have any of these signs

Is your pet having difficulty breathing?

Breathing hard at rest
Elbows sticking outward
Neck stretched forward
Blue tinge to gums
Panting for no reason
Using belly to breathe
Becoming tired/breathing hard very quickly when moving around
Coughing
Wheezing
Gurgling
No, my pet does not have any of these signs

Does your pet have a change in appetite?

Stealing food - acts starving
Hungry all the time
Somewhat increased appetite
Normal appetite
Somewhat decreased appetite
Picky
Not eating much at all
Only eating treats
Not eating at all

If yes, how many days?

Is your pet nauseated? Please note that pets can be nauseated without vomiting.

Going to food but won't eat it
Licking lips when smelling food
Gulping
Gagging
Backing away from food
Trying to bury food
Decreased/poor/no appetite
Drooling
No, my pet does not have any of these signs

Is your pet difficult to keep clean and dry?

Not grooming as much
Not grooming at all
Gets urine on fur
Gets stool on fur
Has mats/knots in the coat
Has discolored fur from urine, stool, or saliva
Has sore spots on skin from urine, stool, or saliva
Smells bad
No, my pet does not have any of these signs

If your pet has an odor, what part of their body?

Does your pet have difficulty using the bathroom?

Difficulty urinating
Frequent urinating
Difficulty passing stool (too hard)
Diarrhea
Urinating in the house
Having bowel movements in the house
No, my pet does not have any of these signs

Is your pet dehydrated?

Drinking more than usual
Urinating more than usual
Not drinking at all
Not drinking much
Urinating less
Not urinating
Gums dry and tacky
Eyes look dry or dull
Eyes sunken
Skin stands up in place or is slow to return to a normal position when lifted gently
No, my pet does not have any of these signs

Is your pet vomiting?

Is your pet still interested in family members?

No, not at all
No, but never has been
Yes, but not as much as before
Yes, as much as always

Is your pet still interested in toys/playing?

No, not at all
No, but never has been
Yes, but not as much as before
Yes, as much as always

Has your pet had a change in behavior that was not addressed above?

Sleeping in unusual places
Hiding
Pacing
Whining
Howling/crying
Biting
Growling
Having accidents in the house
Showing fear or dislike of unusual things
Getting lost
Getting stuck
Seeming confused
Panic

Do you think your pet is unhappy?

Most of the time
Some of the time
Occasionally
Rarely
Never

What makes your pet happy?

Does your pet have more bad days than good days?

YES
About Equal
NO

Is your pet anxious or needy?

No, not at all
No, but never has been
Yes, but not as much as before
Yes, as much as always

Is your pet having difficulty with vision that seems to cause distress?

Is your pet having difficulty with hearing that seems to cause distress?

Any of these signs are cause for concern and warrant a trip to the veterinarian. Once you click submit, an email will be delivered to you that you can print if you would like to take it to your veterinarian. Our doctor will contact you as soon as possible to go over your pet's history.

I have read and understand.

Anything else you think we should know?

We are advocates for your quality of life as well as your pet’s. Please answer the following questions. No judgment here! This helps us know if caregiver fatigue is something we need to address.

Is your sleep disturbed regularly because of your pet? *

Yes, every day
Yes, multiple times a week
Yes, weekly
Yes, a few times a month
Yes, monthly or less
No
Prefer not to answer

What is your pet doing that disturbs your sleep? *

Have you had to change your routine or are you unable to leave your pet alone? *

Yes
No
Prefer not to answer

Please describe *

Is your pet causing or aggravating mental or physical issues for you? *

Yes, anxiety
Yes, depression
Yes, orthopedic pain
Yes, my pet is biting me
Yes other
No
Prefer not to answer

Please describe how your pet is affecting your health *

Is your pet’s condition causing financial difficulties? *

Yes
No
Prefer not to answer

Are you having conflict with others about your pet’s health? *

Yes (This is extremely common and nothing to be ashamed of)
No
Prefer not to answer

Please describe any issues you are facing. *

Phone