Peaceful Shores
 

    My pet:

    1 Strongly Agree
    (All The Time/Severe)

    2 Agree
    (Most of the Time/Significant)

    3 Neutral
    (Sometimes/Mild)

    4 Disagree
    (Occasionally/Slight)

    5 Strongly Disagree
    (Never/None)

    My Pet:

    Does not want to play

    12345

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

    12345

    Does not enjoy the same activities as before.

    12345

    Is hiding.

    12345

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

    12345

    Does not seem to enjoy life.

    12345

    Has more bad days than good days.

    12345

    Is sleeping more than usual.

    12345

    Seems dull and depressed.

    12345

    Seems to be or is experiencing pain.

    12345

    Is panting (even while resting.)

    12345

    Is trembling or shaking.

    12345

    Iis vomiting and/or seems nauseous.

    12345

    Is not eating well (may only be eating treats or only if fed by hand.)

    12345

    Is not drinking well.

    12345

    Is losing weight.

    12345

    Is having diarrhea often.

    12345

    Is not urinating well.

    12345

    Is not moving normally.

    12345

    Is not as active as normal.

    12345

    Does not move around as needed.

    12345

    Needs my help to move around normally.

    12345

    Is unable to keep self clean after soiling.

    12345

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

    12345

    My pet's overall health has improved since the initial diagnosis.

    12345

     

    Survey used with permission, created by:

    www.vet.osu.edu/honoringthebond: Joelle Nielsen, MSW, LSW; The HHHHHMM Quality of Life Scale: Dr. Alice Villalobos; Quality of Life Survey: Dr. David Vail; End-of-Life Values and Goals worksheet, University of Tennessee Veterinary Social Work Department

    *This Quality of Life survey is for your information; it is NOT sent to Dr. Kennedy. If the score you receives indicates you need to schedule a consult or a euthanasia appointment, please contact Dr. Kennedy.