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hello@rousehillfamilyvets.com.au
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Quality of Life Assessment Form

APPOINTMENT

Please fill out this form as completely and accurately as possible before your pet’s procedure. If you have questions, don’t hesitate to give us a call at 02-9086-9130.

Email *

Pet's name *

Your full name *

Date Form Submitted

PAIN

Signs of pain can be subtle such as an elevated respiratory rate or laboured breathing, pacing in the house or yard, stiffness, difficulty sitting or standing and reluctance to exercise. Remember lameness is a definite indicator of pain even if they are still running or playing readily.

Pain *

Point = Your pet does not appear to be in pain. They are moving freely, keen for exercise and sleeping well
2 Points = Your pet has been assessed by a vet recently and prescribed appropriate pain relief for their condition. This medication is working well.
3 Points = Your pet appears painful. They may be vocalising, unable to rest or reluctant to move. Pain medication has been prescribed and is not working adequately or the side effects of medication are severe. Alternative therapies such as acupuncture as a pain management technique have been exhausted.

Appetite *

1 Point = Your pet is eating normally and their appetite is good
2 Points = Their appetite is reduced and they need encouragement to eat or are only eating their favourite foods. They may seem to eat more slowly than usual.
3 Points = Appetite is intermittent or even gone completely. Alternatively your pet may be keen enough to eat but there is then vomiting and nausea or diarrhoea.

Demeanour *

1 Point = Your pet appears happy and is keen to interact with you. They greet you readily and are willing to receive attention.
2 Points = Your pet may be a bit irritable and grumpy compared with their normal self. They are still interested in daily family activities but may also be seeking more time to themselves.
3 Points = Hiding and avoiding interaction have become the norm. They appear depressed much of the time and no longer enjoy activities they previously did.

Mobility *

1 Point = Energy levels are good and exercise or play is still part of their day
2 Points = Your pet is starting to "slow up" but is managing well with their prescribed medications and can happily do about half of the amount of activity they could do in their youth.
3 Points = Your pet's mobility is dramatically reduced. This may mean they need assistance to stand and navigate the house or that they have little capacity for exercise. You may have noticed they can no longer manage stairs or get into the car themselves.

Hydration *

1 Point = Water intake is normal
2 Points = Water intake is abnormal to some degree. In many cases drinking will increase, in others your pet will not be drinking enough.
3 Points = Your pet's level of hydration is inadequate and they require intervention from you (such as syringing or fluids under the skin) to get through the day. Vomiting or diarrhoea may be contributing.

Weight *

1 Point = Your pet is an ideal body weight range and is maintaining their body condition well.
2 Points = Your pet in an unhealthy weight however you are monitoring their body shape and change is slow.
3 Points = Weight changes are uncontrolled and increasing or decreasing their food doesn't seem to make any difference. You may have noticed a rapid change to their body shape such as narrowing at the hips from muscle wasting or bloating of the belly.

Hygiene *

1 Point = Toileting patterns are normal and your pet is still grooming normally
2 Points = You have noticed toileting is not normal. They may have difficulty eliminating, be urinating more frequently or passing stools that don't look normal. You may find their personal hygiene has deteriorated and they require some assistance to keep clean.
3 Points = Your pet is unable to toilet normally. They may have developed urinary or faecal incontinence, may be unstable to get up from soiled bedding, are often less likely to groom and may go on to develop pressure sores on parts of the body. Their requirement for hygiene care has dramatically increased and is exceeding your capacity to provide it.

Rest *

1 Point = Your pet is sleeping normally
2 Points = Your pet sleeps normally most nights but has started sleeping for longer periods than before. They are occasionally disorientated or confused by where they are and who is around.
3 Points = Your pet is unable to settle, anxious and uncomfortable when lying down. They may whimper or cry at night and require medication for a restful sleep. They are often disorientated and cannot be easily calmed.

Your Personal Thoughts *

This section is for your uncensored thoughts. This is not something we want you to score out of 3 and purely a place for you to write your observations and concerns. Jot down notes on how you are feeling and coping as you approach these end of life questions. We know that caring can be daunting and exhausting for even the most dedicated pet parents.

Making a difference when it matters the most

Address

10/591 Withers Road,
Rouse Hill NSW 2155

Click here for directions.

Opening Hours

Monday - Thursday: 9am - 6pm
Friday: 9am - 5pm
Saturday: 9am - 1pm
Sunday & Public Holidays Closed

In-home euthanasia services run outside of opening hours by appointment only

Contact

Phone: 02 9086 9130
Email: hello@rousehillfamilyvets.com.au

Have a question?

Please fill out the form below and a member of our team will be in touch with you shortly. Alternatively please contact us directly at 02 9086 9130.

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