Quality of Life Assessment

Your Full Name *

Phone Number *

Email Address *

Pet's Name *

Activity Levels

Have they lost interest in activities (eg: walks, playing with a favourite toy, etc.)? *

Do they have difficulty when trying to stand or get up from a lying position? *

Are they no longer able to go up/down stairs, or do they avoid certain areas of your home(certain types of flooring)? *

Do they avoid certain physical activities (such as walking on a certain leg/foot, or walking at all)? *

For cats, is your pet struggling to jump onto higher surfaces?

Do they need help to get around normally? *

Appetite

Has the amount of food they consume gone down/up? *

Are they not eating the things they used to love? *

Do they turn down offers of treats or cookies? *

Has the amount of water they’re drinking gone down or up significantly? *

Attitude

Has there been changes to how they interact with some family members? *

Does your pet seem less interested in giving you affection? *

Has their interest or willingness to come to you and engage with you become reduced? *

Are they hiding more and seeking to be alone more than they have in the past? *

Does it seem like they’re not responding to your affection as much as usual? *

Assess a Comfortable Week at Home

Date	Mobility	Nutrition	Hydration	Attitude	Elimination	Favourite Things	TOTAL

MOBILITY
2 Good Mobility – No difficulty getting around, enjoys walks and going outside
1 Poor Mobility – Difficulty getting up, hard to get in position to eliminate, short walks only
0 Bare Minimum Mobility – Needs assistance, pain medication/anti-inflammatory medications do not help

NUTRITION
2 Good Appetite
1 Poor Appetite – Hand feeding, needs enticing
0 No Appetite

HYDRATION
2 Adequate Intake
1 Poor Intake or increased in some patients with particular diseases
0 no intake

INTERACTION/ATTITUDE
2 Interacts normally with family and other pets
1 Some interaction with family and other pets
0 Hides away from you or others

ELIMINATION
2 Normal urination and/or defecation
1 Poor Appetite – Hand feeding, needs enticing
0 No Appetite

FAVOURITE THINGS
2 Enjoys doing favourite activities, hobbies, etc.
1 Decrease in enjoyment of their favourite things
0 No interest in their favourite things

DAILY TOTAL
12 – 9 Everything is okay
6 – 8 Requires intervention
5 or less: Speak to your veterinarian about considering euthanasia

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Quality of Life Assessment

Activity Levels

Appetite

Attitude

Other Questions

Assess a Comfortable Week at Home

Date

Mobility

Nutrition

Hydration

Attitude

Elimination

Favourite Things

TOTAL

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