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Pet Quality of Life Survey

This survey will help you, and Dr. Kennedy, determine if your beloved pet is in need of either hospice care or a euthanasia appointment. It’s designed to identify the symptoms and behavior that indicate if your pet’s quality of life has been negatively impacted.  


Simply choose your answer to each question as accurately as possible. The survey will tally your answers and provide a result, which will also be emailed to you. The result will let you know if you need to reach out to Dr. Kennedy for either a hospice consult or a euthanasia appointment … or if your pet is doing fine for right now and no action is required.

General Information

What is your first name?

What is your last name?

What is your pet's name?

What is your email?

What is your phone number?

Survey Questions

My pet...

Does not want to play.

Does not want to play.
1
2
3

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

Does not respond to my presence or does not interact with me in the same way as before.
1
2
3

Does not enjoy the same activities as before.

Does not enjoy the same activities as before.
1
2
3

Is hiding.

Is hiding.
1
2
3

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

Demeanor/behavior is not the same as it was prior to diagnosis/illness.
1
2
3

Does not seem to enjoy life.

Does not seem to enjoy life.
1
2
3

Has more bad days than good days.

Has more bad days than good days.
1
2
3

Is sleeping more than usual.

Is sleeping more than usual.
1
2
3

Seems dull and depressed.

Seems dull and depressed.
1
2
3

Seems to be or is experiencing pain.

Seems to be or is experiencing pain.
1
2
3

Is panting (even while resting.)

Is panting (even while resting.)
1
2
3

Is trembling or shaking.

Is trembling or shaking.
1
2
3

Is vomiting and/or seems nauseous.

Is vomiting and/or seems nauseous.
1
2
3

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

Is not eating well (may only be eating treats or only if fed by hand.)
1
2
3

Is not drinking well.

Is not drinking well.
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3

Is losing weight.

Is losing weight.
1
2
3

Is having diarrhea often.

Is having diarrhea often.
1
2
3

Is not urinating well.

Is not urinating well.
1
2
3

Is not moving normally.

Is not moving normally.
1
2
3

Is not as active as normal.

Is not as active as normal.
1
2
3

Does not move around as needed.

Does not move around as needed.
1
2
3

Needs my help to move around normally.

Needs my help to move around normally.
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2
3

Is unable to keep itself clean after soiling.

Is unable to keep itself clean after soiling.
1
2
3

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

Has a coat that is greasy, matted, or rough-looking.
1
2
3

Survey used with permission, created by: 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