Please print this form before hitting the submit button.

This form is not needed if the sole purpose of the visit if for a Euthanasia.  This form is only needed if you are requesting a Quality of Life assessment or a Hospice visit.  Having accurate background medical history on your pet is extremely important in order for the doctor to help you assess your pet's Quality of Life and devising a hospice care plan.  Filling out this form as completely and as accurately as possible will streamline the hospice consultation and will help the doctor gather valuable medical history about your pet which will lead to the consultation time being spent on discussing important concerns you have about your pet and his Quality of Life rather than spending time gathering the medical history.  Please give us as many details as you can.

Pet owner information
Enter your information here
Your pet's general information
Veterinarian

As a courtesy, Home Pet Euthanasia will update your veterinarian on the visit and course of treatment of your pet so that they may update their records and advise us of any diagnosis or tests that may be relevant to your pet's hospice care or choice of medication.

The information you will provide about your pet will help us greatly on deciding on the course of action that will be most beneficial for your pet and your family.

Please answer the following questions as accurately as possible.

Symptoms
On a scale of 0 (none) to 5 (extreme), please rate each of these symptoms
012345
Vomiting?
Diarrhea?
Constipation?
Coughing?
Sneezing?
Skin conditions? (itching, hair loss, redness, etc...)
Seizures? (frequency,duration)
Excessive drinking?
Excessive urinating?
Urine Incontinence?
Fecal incontinence?
Accidents?
Limping?
Dementia?
Lack of appetite?
Excessive appetite?
Weight loss?
Weight gain?
Halitosis? (foul breath)
Please include test names, results and doctor comments. If possible, please have medical records faxed ahead of time so that the doctor can review any pertinent medical history and test results.
Please describe any treatments such as medication, chemo, radiation, surgeries, etc...
Please give details on response to treatment, medication reactions, improvements, etc...
(Please list all medication and neutraceuticals your pet is currently receiving as well as the dose and frequency)
Please list any RELEVANT medication or neutraceutical your pet has been on in the past.
List any medication reactions your pet has ever had in his life. Give the name of the medication, what happened and when it was.
Enter any dry food, canned food as well as any table foods and treats.

The following test will help us greatly in evaluating your pet's Quality of Life.  It should be done as early as possible in the End of Life process and repeated periodically in order to monitor your pet's progress.  It will help you in determining when it will be time to euthanize to your pet so that you do not push your pet beyond acceptable Quality of Life.  For more information on how to evaluate Quality of Life, please visit our Quality of Life page.

QUALITY OF LIFE TEST
Evaluate each Quality of Life criterion to the best of your ability by selecting a number from 1-10 (1=very poor; 10=perfect). For more information on how to evaluate each criterion, please visit our Quality of Life page.
Adequate pain control, including breathing ability, is of top concern. Trouble breathing outweighs all concerns. Is the pet's pain successfully managed? Can the pet breathe properly? Is oxygen supplementation necessary?
Is the pet eating enough? Does hand feeding help? Does the patient require a feeding tube?
Is the patient dehydrated? For patients not drinking enough, use subcutaneous fluids once or twice daily to supplement fluid intake.
The patient should be brushed and cleaned, particularly after elimination. Avoid pressure sores and keep all wounds clean.
Does the pet express joy and interest? Is the pet responsive to things around him or her (family, toys, etc.)? Is the pet depressed, lonely, anxious, bored or afraid? Can the pet's bed be close to the family activities and not be isolated?
Can the patient get up without assistance? Does the pet need human or mechanical help (e.g., a cart)? Does the pet feel like going for a walk? Is the pet having seizures or stumbling? (Some caregivers feel euthanasia is preferable to amputation, yet an animal who has limited mobility but is still alert and responsive can have a good quality of life as long as caregivers are committed to helping the pet.)
When bad days outnumber good days, quality of life might be compromised. When a healthy human-animal bond is no longer possible, the caregiver must be made aware the end is near. The decision for euthanasia needs to be made if the pet is suffering. If death comes peacefully and painlessly at home, that is okay.
*A total over 35 points represents acceptable life quality

The pain indicators list below will help you determine if your pet is in pain and how much pain he is in.  Please rate each of these criteria from 0-10 (0 meaning that he is not exhibiting this indicator at all and 10 being severe).  Please note that each symptom taken individually does not necessarily mean that your pet is in pain.  It is the overall rating of the majority of symptoms that will help guide us. 

For more information on pain, please visit our "Understanding Pet Pain" page.

012345678910
1. Droopy head *
2. Droopy ears *
3. Tucked tail *
4. Does not want to play *
5. Lack of social interaction *
6. Does not enjoy games *
7. Subtle lack of alertness gradually increasing to a deep apathy (early sign will be subtle) *
8. Diminished appetite *
9. Body tension *
10. Facial tension *
11. Accepting treats or food gingerly (particularly if pet used to accept them enthusiastically) *
12. Lack of interest in walks *
13. Doesn't respond when called *
14. Worried or sad facial expression *
15. Ears pulled back or flattened *
16. Eyes wide open to expose “white of the eye” *
17. Avoidance of direct eye contact *
18. Lips may be retracted, exposing the teeth in a submissive grin (dogs) *
19. Almond shaped eyes (caused by facial tension) *
20. Whiskers pulled back against cheeks (caused by facial tension) *
21. Uncomfortable when resting *
22. Shifts frequently when resting *
23. Head held abnormally low *
24. Difficulty getting up *
25. Excessive panting (particularly when it is not hot) *
26. Shivering/trembling/shaking *
27. Unsettled *
28. Pacing *
29. Difficulty moving after a long rest *
30. Difficulty lying down *
31. Slow or unusual gait *
32. Limping *
33. Hunched back *
34. Compulsive licking or rubbing of a certain body part *
35. Looking at sides or other body part suddenly and/or worriedly *
36. Suddenly running away from “nothing in particular” *
37. Can't jump on couch or bed *
38. Reluctance to lie down *
39. Sleeps in a position that avoids a certain body part from touching the ground or bed *
40. Any change in normal sleep patterns *
41. Purplish tongue color (NOT gums: tongue) *
42. ”Guards” a particular body part *
43. Reluctance to be touched in a certain area *
44. Reluctance to be picked up *
45. Lying down at a distance from everybody and somewhat isolated *
46. Disinterested in surroundings *
47. Unusual attention seeking *
48. Flinching when touched in a certain area *
49. Doesn't rest easily when lying down *
50. Aggressive behavior to protect a particular area *
51. Aggressive behavior on a usually docile pet *
52. Crying when a particular area is touched *
53. Wakes up at night *
54. Does not sleep well *
55. Refusal to go on walks *
56. Moaning *
57. Whimpering *
58. Refusing to eat *
59. Pressing head against wall (if head pain is present) *
60. Unable to get up *
61. Crying in pain *
62. Teeth clenched, biting down on an object (particularly cats) *
63. Howling/screaming uncontrollably *
Do you have religious/spiritual beliefs that you wish us to know about and which should be taken into consideration during your pet’s hospice care and/or euthanasia? Telling us about your beliefs will help us honor and respect them.
Please feel free to say as much as you like.
Agreement

Your pet’s hospice care is a matter we take to heart.  We will do our very best to ensure that your pet has the most comfortable End of Life experience possible.  Caring for a terminal pet can be time consuming and requires a commitment both on your part and on our part.  Therefore communication between doctor and pet parent it is of prime importance.  For routine updates, please email the doctor.  For urgent matters, you can contact us 24/7 via phone at 714-454-4080.  Do not use text messages under any circumstance.  In the case of urgent matters, it is possible that you may speak to a different doctor than the one who did the original hospice consultation, depending on who is on call at the time.  For prescription refills, please contact the doctor via email at least 3 days in advance.  For refill authorizations of prescriptions, you may be required to repeat the Quality of Life scale, the pain indicators table as well as give us an update on how your pet is doing so that we may adjust the dosage and prescriptions in your pet’s best interest.  The first consultation fee includes a one hour consultation in your home and one month of email follow-ups.  Over-the-phone follow-ups are subject to a fee of $50/15 minutes.  Follow-up hospice (not euthanasia) visits within one month of the original visit are offered a 50% discount of the full price (excluding any applicable travel and off hours fee).  An update on Quality of Life scale and pain table are required to benefit from discounted fee on monthly visits.  A fee of $100 per month will be assessed for email follow ups after the first month.  This fee will be waived if a follow-up home visit is made within one month of original visit.  We have 5 amazing doctors in our team. Each doctor was chosen for her exceptional compassion and caring.  Due to our doctors' schedules (both personal and professional), it may not be possible for the same doctor who attended your pet's hospice visit(s) to be the one helping you with your pet's euthanasia.  Rest assured that your pet, you and your family will be treated with the utmost compassion regardless of which doctor helps you during the course of your pet's hospice and euthanasia.

Electronic signature

Please print this form before hitting the submit button.