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Quality of Life Evaluation
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» Quality of Life Evaluation
Are you an existing client with our practice?
*
Yes, I am existing client with an existing patient
Yes, I am existing client with a new patient
No, I am wishing to become a client
No, I would just like a copy for myself
Today's Date:
*
Date Format: MM slash DD slash YYYY
Owner's Name:
*
First
Last
Email
*
Enter Email
Confirm Email
Phone #:
*
Pet's Name:
*
Pet's Approximate Weight:
*
Happiness
My pet wants to play
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1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet responds to my presence
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet enjoys life
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
Mental State
My pet has more good days than bad days
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1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet sleeps more, is awake less
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet settles well and sleeps through the night
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet seems dull or depressed, not alert
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
Pain
My pet is in pain
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet pants frequently, even at rest
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1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet shakes or trembles occasionally
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1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
Appetite
My pet eats the usual amount of food
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1 - Disagree (not eating at all)
2- Somewhat disagree (eating much more or much less)
3 - Neutral (will eat things other than their food)
4 - Somewhat agree (may skip a meal or not finish a meal)
5 - Agree (my pet's appetite has not changed)
My pet acts nauseous or vomits
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet eats treats/snacks
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1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
Hygiene
My pet keeps himself/herself clean
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet smells like urine or has skin irritation
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet's hair is greasy, matted, rough looking
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1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
Hydration
My pet drinks adequately
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1 - Less than normal
2 - Normal
3 - More than normal
My pet has abnormal stool
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1 - Disagree (normal stools every time)
2 - Somewhat disagree (i.e. occasional soft or hard stool)
3 - Neutral
4 - Somewhat agree (i.e. frequent soft or hard stools)
5 - Agree (constant diarrhea, soft stools, hard stools, etc.)
My pet is urinating a normal amount
*
1 - Less than normal
2 - Normal
3 - More than normal
4 - My pet is urinary incontinent
Mobility
My pet moves normally
*
1 - Disagree (significant difficulty getting around)
2 - Somewhat disagree (i.e. he/she limps occasionally)
3 - Neutral
4 - Somewhat agree (i.e. occasional stiffness, but returns to normal)
5 - Agree (no mobility issues)
My pet lays in one place all day long
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
My pet is as active as he/she has always been
*
1 - Disagree
2 - Somewhat disagree
3 - Neutral
4 - Somewhat agree
5 - Agree
General Health
General health compared to initial diagnosis
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1 - Worse
2 - Somewhat worse
3 - Similar
4 - Somewhat better
5 - Significantly better
General health compared to last evaluation
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1 - Worse
2 - Somewhat worse
3 - Similar
4 - Somewhat better
5 - Significantly better
My pet's quality of life is
*
1 - Very poor
2 - Poor
3 - Fair
4 - Good
5 - Excellent
Additional information, comments or questions:
https://happierathomevet.com/forms/new-client-registration-form/
https://happierathomevet.com/forms/new-patient-registration-form/
After clicking "Submit" below, a copy of this form will be emailed to us. If you have any additional questions/comments/concerns, please reach out to us directly.
After submitting, you will be redirected to the home page.
After clicking "Submit" below, a copy of this form will be emailed to us and the email address you entered above.
After submitting, you will be redirected to the home page.
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Home
About Us
Our Team
Services
Wellness and Vaccinations
Preventive Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Exotic Pet Medicine and Surgery
End of Life Services
Pet Health
How-To Videos
Pet Food Recalls
Product Recalls
Contact Us
Online Pharmacy
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