Now accepting new clients!

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)

Name *

First

Last

Pet's Name

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

Desire to be with family has not changed.

Interacts normally with family or other pets (ie. no increased aggression or other changes).

Natural Functions

Appetite has stayed the same.

Drinking has stayed the same.

Urination habits have stayed the same.

Bowel movements have stayed the same.

Ability to walk around has stayed the same.

Mental Health

Enjoys normal play activities.

Still dislikes the same things.

No outward signs of stress or anxiety.

Does not seem confused.

Nighttime activity is normal, with no changes seen.

Physical Health

Shows no changes in breathing or panting patterns.

Shows no outward signs of pain.

Does not pace around the house.

Please tally up your score here

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

My pet is suffering.

My desire to perform nursing care for my pet.

My ability to perform nursing care for my pet.

My pet dying alone.

Not knowing the right time to euthanize.

Coping with loss.

Concern for other animals in my household.

Concern for other members of the family.

Please tally up your score here

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

In general, how do you rate your pet's health?

Excellent
Very Good
Good
Fair
Poor

Has your pet seen a veterinarian because of join pain, stiffness, or limping?

Living in pain can lead to changes in behavior, which can be hard to read in a pet. On average, would you say your pet...

Seems completely uninterested in its surroundings; sleeps all the time.
Will show interest but no longer comes to greet you
Is mostly interested in life and food, but reluctant to play
Plays only when encouraged, and not for long
Has no change in personality

(Please only select one)

Has your pet's activity level changed? (If yes, select all that apply)

Seeks more affection than usual
Lies very still
Becomes restless
Shows circling
Has difficulty getting up from a lying position
Shows trembling
Reluctant to move
Repetitively gets up and lies down

Has your pet's appetite or thirst changed?

Does your pet have trouble in areas where he/she never used to need assistance?

Cannot manage any steps without assistance
Cannot manage a full flight of steps
Manages a full flight of stairs but has difficulty
Can only go UPstairs without assistance
Can only go DOWNstairs without assistance
No problems on stairs
Cannot jump onto furniture without assistance
Cannot get into the vehicle without assistance
Has no problems jumping
Has difficulty posturing to urinate/defecate

Has your pet become protective of him/herself?

Protects hurt body
Doesn't put weight on a limb
Doesn't want to be held or picked up
Hides
Limps

Does your pet have pain, swelling, or stiffness?

Yes, in many joints
Yes, in a few joints
Very rarely
Never

How long does it take before your pet start getting tired, starts limping, or stops walking?

Less than 5 minutes
10-20 minutes
More than 30 minutes/my pet does not get tired
Does not show signs until finished walking and rests for a while

Does your pet favor one side of its body more than the other?

Slowly, over the course of a few months
No signs
Suddenly, within days or a few weeks

Has the joint pain suddenly gotten worst?

Within the past few days
Within the past few weeks
Not applicable

In the morning, are the affected areas stiff for more than 30 minutes?

Yes
No
There is no morning stiffness

Has your pet had join/bone injury or surgery?

Yes
No
Unsure

Which of the following methods do you use to manage your pet's pain, swelling, or stiffness?

Physical activity/exercise
Nutritional supplements
Weight management
Physical rehabilitation/chiropractic/massage
Cold or heat treatment
Medication
None of the above

(Check all that apply)

If you give any medications or supplements currently what do you give?

Does your pet have any of the following conditions?

Kidney disease
Active infection
Bladder problems
Skin disease
Lung disease
Liver disease
Cardiovascular disease

(Check all that apply)

Is there anything else we should know about your pet?

Cognitive Dysfunction Questionnaire

Wanders aimlessly

Never
Sometimes
Often

Appears lost or confused in house or yard

Never
Sometimes
Often

Gets "stuck" in corners or under/behind furniture

Never
Sometimes
Often

Stares into space or at walls

Never
Sometimes
Often

Has difficulty finding the right door to go in/out, or stands on the wrong side

Never
Sometimes
Often

Does not recognize familiar people

Never
Sometimes
Often

Does not respond to verbal cues or name

Never
Sometimes
Often

Appears to forget reason for going outdoors

Never
Sometimes
Often

Interaction with family members

Solicits attention less often

Never
Sometimes
Often

Is less likely to stand/lie for petting (walks away)

Never
Sometimes
Often

Is less enthusiastic upon greeting

Never
Sometimes
Often

No longer greets owners (once dogs is aware that owners have arrived)

Never
Sometimes
Often

Sleep and Activity

Sleeps more (overall) in a 24 hour day

Never
Sometimes
Often

Sleeps less during the night

Never
Sometimes
Often

Shows decrease in purposeful activity in a 24 hour day

Never
Sometimes
Often

Shows increase in aimless activity in a 24 hour day

Never
Sometimes
Often

Housetraining

Urinates indoors

Never
Sometimes
Often

Defecates indoors

Never
Sometimes
Often

Urinates or defecates indoors in front of owner/s

Never
Sometimes
Often

Urinates or defecates indoors soon after being outside

Never
Sometimes
Often

Signals less often to go outside (for dogs that previously signaled to go outside)

Never
Sometimes
Often

Ready for a visit?

We proudly serve the pets of Morrisville, Stowe, Waterbury, Jericho, Montpelier, and surrounding areas. We look forward to seeing you and your pet! You may call to book an appointment by clicking the button below.

Book Appointment