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Quality of Life Form

Save time during your next appointment! Complete your required form online from any device at any time before your visit.

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Quality of Life 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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SOCIAL FUNCTION

Score each item on a scale of 0-2

0 = AGREE, DESCRIBES MY PET
1 = SOME CHANGES
2 = DISAGREE, DOES NOT DESCRIBE MY
PET

MENTAL HEALTH

Score each item on a scale of 0-2

0 = AGREE, DESCRIBES MY PET
1 = SOME CHANGES
2 = DISAGREE, DOES NOT DESCRIBE MY
PET

NATURAL FUNCTIONS

Score each item on a scale of 0-2

0 = AGREE, DESCRIBES MY PET
1 = SOME CHANGES
2 = DISAGREE, DOES NOT DESCRIBE MY
PET

HEALTH

Score each item on a scale of 0-2

0 = AGREE, DESCRIBES MY PET
1 = SOME CHANGES
2 = DISAGREE, DOES NOT DESCRIBE MY
PET

0-8: Quality of life is most likely adequate. No medical intervention is required at this time. Guidance from your
veterinarian may help identify signs to look for in the future.

9-16: Quality of life is questionable and medical intervention is suggested. Your pet would likely benefit from
veterinary oversight and guidance to evaluate disease process

17-32: Quality of life is compromised. Changes are likely to become more progressive and more severe. Veterinary
guidance will help you understand the end stages of your pet’s disease process in order to make a better decision
on continuing hospice care or electing peaceful euthanasia.