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Senior Feline Questionnaire Form

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

Senior Feline 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.

Cat Mobility Questionnaire

My cat is less willing to jump up or down.

Yes
No
Maybe

My cat will only jump up or down from lower heights

Yes
No
Maybe

Shows signs of being stiff at times

Yes
No
Maybe

Has your pet's appetite or thirst changed?

Is less agile than previously

Yes
No
Maybe

Cries when lifted

Yes
No
Maybe

Shows signs of lameness or limping

Yes
No
Maybe

Has difficulty getting in or out of the cat flap/door

Yes
No
Maybe

Has difficulty going up or down stairs

Yes
No
Maybe

Has more accidents outside the litter box

Yes
No
Maybe

Spends less time grooming

Yes
No
Maybe

Is more reluctant to interact with me

Yes
No
Maybe

Plays less with other animals/toys

Yes
No
Maybe

Sleeps more and/or is less active

Yes
No
Maybe

Cries out for no apparent reason

Yes
No
Maybe

Has become more fearful and/or more aggressive

Yes
No
Maybe

Appears forgetful

Yes
No
Maybe

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.

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