Senior Canine Questionnaire Form

Please fill this form out before your appointment if instructed by a member of Sequist AH.

Senior Canine Questionnaire Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 802-888-7776 for a faster response.

Updates on COVID-19 – Hospital Policies For All Appointments
*This form is required for all appointments with a doctor. Please fill this form out at your earliest convenience and at least 24 hours before your appointment.

Evaluation Scale (Part 1)

When evaluating quality of life, it is important to assess your pet's medical condition, but also the wishes of everyone involved in the care of your pet. Complete the scale at different times of the day to see any fluctuations, because most pets do better during the day and worst at night. Multiple family members should complete this scale to compare observations. Take periodic photos of your pet to help remember his/her physical appearance.

Scale for scoring

0 = I agree with the statement (describes my pet)

1 = I see some changes

2 = I disagree with this statement (does not describe my pet)

Social Functions

Natural Functions

Mental Health

Physical Health

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


9 - 16: Quality of life is questionable and medical intervention is suggested. Your pet would benefit from veterinary oversight and guidance to evaluate its disease process.


17 - 36: Quality of life is a definite concern. Changes will likely become more progressive and more severe. 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 care or elect peaceful euthanasia.

Evaluation Scale Part 2

Scale for scoring

0 = I am not concerned at this time

1 = There is some concern

2 = I am concerned about this

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

5 - 9: Your concerns are mounting. Begin by educating yourself on your pets condition, which is the best way to ensure you are prepared for the emotional changes ahead.

10 - 16: Your concerns about your pet are valid. Now is the time to build a support system. Veterinary guidance will help you prepare for the medical changes in your pet and other health professionals can begin helping you with anticipatory grief.

Mobility Questionnaire

(Please only select one)
(Check all that apply)
(Check all that apply)

Cognitive Dysfunction Questionnaire

Interaction with family members

Sleep and Activity