Quality of Life History Form | Animal Medical Center of Mid-America

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When evaluating the quality of life of your pet, personalized patient and family information is important when reaching an educated, informed, and supported choice that fits not only your pet’s medical condition, but also your wishes and expectations. In short, quality of life applies not only to the pet, it also applies to you!

Today's date*

Contact name*

First Last

Contact phone number*

Pet's name*

Score each subsection on a scale of 0-2: 0 = agree with statement (describes my pet) 1 = some changes seen 2 = disagree with statement (does not describe my pet)

Social Functions

Desire to be with the family has not changed*

Please enter a number from 0 to 2.

Interacts normally with family or other pets (i.e., no increased aggression or other changes)*

Please enter a number from 0 to 2.

Health

No changes in breathing or panting patterns*

Please enter a number from 0 to 2.

No outward signs of pain (excessive panting, pacing, and whining are most commonly seen)*

Please enter a number from 0 to 2.

No pacing around the house*

Please enter a number from 0 to 2.

My pet’s overall condition has not changed recently*

Please enter a number from 0 to 2.

Mental Health

Enjoys normal play activities*

Please enter a number from 0 to 2.

Still dislikes the same thing (i.e., still hates the mailman = 0, or doesn’t bark at the mailman anymore = 2)*

Please enter a number from 0 to 2.

No outward signs of stress or anxiety*

Please enter a number from 0 to 2.

Does not seem confused or apathetic*

Please enter a number from 0 to 2.

Nighttime activity is normal, no changes seen*

Please enter a number from 0 to 2.

Natural Functions

Appetite has stayed the same*

Please enter a number from 0 to 2.

Drinking has stayed the same*

Please enter a number from 0 to 2.

Normal urination habits*

Please enter a number from 0 to 2.

Normal bowel movement habits*

Please enter a number from 0 to 2.

Ability to ambulate (walk around) has stayed the same*

Please enter a number from 0 to 2.

Results

0-8: Quality of life is most likely adequate. No medical intervention required yet, but guidance from your veterinarian may help you identify signs to look for in the future.

9–16: Quality of life is questionable and medical intervention is suggested. Your pet would certainly benefit from veterinary oversight and guidance to evaluate the disease process he/she is experiencing.

17-32: Quality of life is a definite concern. Changes will likely become more progressive and more severe in the near future. Veterinary guidance will help you better understand the end stages of your pet’s disease process in order to make a more informed decision of whether to continue hospice care or elect peaceful euthanasia.

Total score added from each section

Lap of Love Pet Family Concerns

Score each item on a scale of 0-2:
0 = I am not concerned at this time
1 = There is some concern
2 = I am concerned about this

I am concerned about the following things:

Pet suffering*

Please enter a number from 0 to 2.

Pet dying alone*

Please enter a number from 0 to 2.

Not knowing the right time to euthanize*

Please enter a number from 0 to 2.

Concern for other household animals*

Please enter a number from 0 to 2.

Desire to perform nursing care for your pet*

Please enter a number from 0 to 2.

Ability to perform nursing care for your pet*

Please enter a number from 0 to 2.

Coping with loss*

Please enter a number from 0 to 2.

Concern for other members of the family (i.e. children)*

Please enter a number from 0 to 2.

Results

0-4: Your concerns are minimal at this time. You have either accepted the inevitable loss of your pet and understand what lies ahead, or have not yet given it much thought. If you have not considered these things, now is the time to begin evaluating your own concerns and limitations.

5-9: Your concerns are mounting. Begin your search for information by educating yourself on your pet’s condition; it’s the best way to ensure you are prepared for the emotional changes ahead.

10-16: Although you may not place much value on your own quality of life, your concerns about the changes in your pet are valid. Now is the time to prepare yourself and to build a support system around you. Veterinary guidance will help you prepare for the medical changes in your pet while counselors and other health professionals can begin helping you with anticipatory grief.

Total score

DISCUSS THE QUESTIONS BELOW, AND THE ENTIRE QUALITY-OF-LIFE SCALE, WITH YOUR VETERINARIAN

Below are some open-ended questions that assist gauge your family’s time, emotional, and (when appropriate, financial) budgets:
1. Have you ever been through the loss of a pet before? If so, what was your experience (good or bad, and why)?
2. What do you hope the life expectancy of your pet will be? What do you think it will be?
3. What is the ideal situation you wish for your pet’s end of life experience? (at home, pass away in her sleep, etc.)

Suggestions on using this quality-of-life scale:
1. Complete the scale at different times of the day, note circadian fluctuations in well-being. (We find most pets tend to do worse at night and better during the day.)
2. Request multiple members of the family complete the scale; compare observations.
3. Take periodic photos of your pet to help you remember their physical appearance.

Resources:
1. AAHA/AAFP Pain Management Guidelines for Dogs and Cats, www.aahanet.org/Library/PainMgmt.aspx

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