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Family Concerns Form

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Family Concerns Form

Please complete this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.
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I AM CONCERND ABOUT THE FOLLOWING THINGS

0 = NOT CONCERNED AT THIS TIME 1 = THERE IS SOME CONCERN 2 = I AM VERY CONCERNED ABOUT THIS

RESULTS:

0-4: Concerns are minimal at this time. You have accepted that your pet is nearing their end of life and understand what lies ahead.

5-9: Your concerns are mounting. Begin asking yourself and your veterinary staff questions about your pet’s condition. Ensure you are prepared for changes in your pet’s life.

10-16: Your concerns about your pet are valid. Now is the time to prepare yourself and build a support systems around you. Your veterinary staff’s guidance

SUGGESTED DISCUSSION QUESTIONS & ACTIVITIES TO GO OVER AS A FAMILY OR WITH YOUR VETERINARY STAFF:

Open ended questions to use with your veterinary staff or as a family:

Suggestions on using this Quality-of-Life Scale:
1. Complete the scale at different times of the day; note fluctuations in your pet’s well-being
2. Have multiple family members complete the scale, compare observations
3. Take periodic pictures of your pet to help catalog their physical appearance and/or changes