End-of-Life Guidance Questionnaire End-of-Life Guidance QuestionnairePlease fill out the following questionnaire so that we can be better prepared for our visit.Pet NamePet AgePet Weight (in lbs.)Pet SpeciesHas your pet been diagnosed with a chronic condition that is the primary reason for his/her decreased quality of life? Yes NoWhat condition has your pet been diagnosed with?Has your pet bitten anyone in the last 10 days? Yes NoIs your pet healthy, but you want to euthanize him/her? Yes No Please answer the following to the best of your ability. Check all that apply.PAINMany animals do not complain in obvious, visible ways. Many animals (especially cats) will hide their discomfort.Consider the following: My pet hurts. My pet limps (if it didn’t hurt, he wouldn’t limp.) My pet pants frequently, even at rest. My pet’s respirations are forced, exaggerated, or otherwise not normal. My pet licks repeatedly at one site on her body or at a site of a cancer/tumour. My pet guards or protects and area of his body and may snap if that area is approached or touched. My animal’s posture is abnormal or different than normal. My pet shakes or trembles sometimes during rest. My pet is on pain medication and it doesn’t work.APPETITEAppetite is one of the most obvious signs of wellness. Most animals are normally vigorous eaters. Consider the following: My pet doesn’t eat his normal food anymore. My pet picks at her food now but never used to do this. My pet walks over to his food and looks at it but won’t eat or walks away from the food. My pet doesn’t even want good stuff (treats, human foods, snacks) anymore. My pet acts nauseas or vomits. My pet is losing weight.HYDRATIONHydration status is equally important as appetite. Dehydration can contribute to weakness and not feeling well. Consider the following: My pet doesn’t drink as much as she used to. My pet frequently has dry, sticky gums. My pet is vomiting or has diarrhoea.HYGIENEAnimals that don’t feel well, especially cats, do not have the energy to maintain normal hair and skin. Consider the following: My cat doesn’t groom herself any more. My pets hair is matted, greasy, rough looking, dull, or foul smelling. My pet has stool pasted around his rectum or in his hair. My pet smells like urine or has skin irritation from urine. My pet has pressure sores/wounds that won’t heal.ACTIVITY/MOBILITYChanges in normal activity can be due to mobility problems, pain, illness, or aging (arthritis). Consider the following: My pet cannot get up without assistance. My pet had a hard time getting around and/or limps. My pet lays in one place all day long. My pet does not want to play ball, go for walks, or do the things he used to do. My pet falls frequently.HAPPINESS/MENTAL STATUSAnother important area of consideration is your pet’s mental status and happiness. Consider the following: My pet does not express joy and interest in life. My pet does not respond to the people that he used to respond to. My pet does not want to play with toys or do other things that he used to enjoy. My pet seems dull, not alert, or depressed.GENERAL BEHAVIOR PATTERNSChanges in normal behavioural patterns are often a key indicator of how your pet is feeling. Consider the following: My pet is hiding or sleeping in odd places. My pet doesn’t greet me when I come home and he used to. My pet is overly clingy and is following me around and he never used to do this. My other pets are treating my pet differently and they are overly attentive or ignoring him completely. My pet doesn’t care about what is going on around him.OWNER PERCEPTIONSMany times you, the ‘parent’ or owner is aware that your pet is suffering but do not want to give up on them. Consider the following: I wouldn’t want to live if I were in a similar situation. I would be painful if I were in a similar situation. I have made appointments for euthanasia for this pet cancelled or didn’t show up. I am holding onto this pet for a sentimental (personal) reason.Your First NameYour Last NameEmailThank you for taking the time to answer these questions! This will make our time together in the future much more productive.Submit Form
