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Dr Duncan HoustonDr Duncan HoustonWritten by a practising veterinarian

Quality of Life Assessment Form

A free fillable quality of life assessment for veterinary use. Work through it with the owner, sign on screen, then print it or save it as a PDF. Patient and owner details are never stored or sent anywhere.

Clinic

Clinic & Assessment Details

Client

Client's Details

Patient

Patient's Details

Assessment

Quality of Life Assessment

1. Are we suffering / in pain?
2. Are we still eating / drinking?
3. Is there anything more that can be done?
4. Can we urinate / defecate on our own?
5. Are there still moments of happiness / are there things in life that we still enjoy?
Sign-off

Veterinary Sign-Off

Veterinarian signature
Preview

Quality of Life Assessment Form

Live preview · prints exactly like this

Quality of Life Assessment Form

Clinic & Assessment Details

Date of assessment

Client's Details

First name
Last name
Address
Phone
Email

Patient's Details

Name
DOB (age)
Microchip
Weight (kg)
Gender
Desexed
Species
Breed
Colour
Markings

Quality of Life Assessment

1. Are we suffering / in pain?
2. Are we still eating / drinking?
3. Is there anything more that can be done?
4. Can we urinate / defecate on our own?
5. Are there still moments of happiness / are there things in life that we still enjoy?
What conditions do we have?
Notes

Veterinary Sign-Off

Veterinarian name
Date signed

Veterinarian signature

Built by Dr Duncan Houston for Ask A Vet · askavet.com

Nothing typed into this form is sent to or stored by askavet.com. All data stays in your browser and leaves only in the PDF or printout you create. Check the record-keeping requirements of your local veterinary regulator before use.

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Dr Duncan Houston
About the author

Dr Duncan Houston · BVSc, Veterinarian

Emergency careGeneral practiceMobile vet careFounder, ASK A VET™

Dr Duncan Houston is an Australian veterinarian with experience in emergency, general-practice and mobile veterinary care. He is the founder of ASK A VET™. This guide is educational and is not a substitute for hands-on veterinary care.

When Remember is on, this page saves your clinic's details in this browser only. Owner and patient details are never saved. It is never sent to Ask A Vet. Use Forget to remove them from this computer.