Quality of Life Questionnaire

Owner Details

Email:

Phone:

Pet Details

Pet's Name:

Pet Species:

Pet Breed:

Pet Sex:

MaleFemale

Pet Date of Birth:

Pet Age:

Survey Date:

Weight of Your Pet:

My Pet

Does not want to play:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

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

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Does not enjoy the same activities as before:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is hiding:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

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

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Does not seem to enjoy life:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Has more bad days than good days:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is sleeping more than usual:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Seems dull and depressed:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Seems to be or is experiencing pain:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is panting (even while resting):

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is trembling or shaking:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is vomiting and/or seems nauseous:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

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

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is not drinking well:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is losing weight:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is having diarrhea often:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is not urinating well:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is not moving normally:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is not as active as normal:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Does not move around as needed:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Needs my help to move around normally:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Is unable to keep self clean after soiling:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

Has coat that is greasy, matted, or rough-looking:

Strongly Agree (Always) (Severe)Agree (Most of the time) (Significant)Neutral (Sometimes) (Mild)Disagree (Occasionally) (Slight)Strongly Disagree (Never) (None)

How is my pet’s overall health compared to the initial diagnosis/illness?

Rate your pet's current quality of life

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Quality of Life Questionnaire

HIGHlands Locations We Serve

Contact Details

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Quality of Life Questionnaire

HIGHlands Locations We Serve

Contact Details

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