Pet parent quality of life assessment form - COSMIC LIGHT

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Pet parent quality of life assessment form

The HHHHHMM Scale
Pet parents can use this Quality of Life Scale to determine the success of Comfort Care. Score patients using a scale of 1 to 10 with 10 being ideal.

* Indicates required field

Pet's name *

Pet's age *

Pet parent's Name *

First

Last

Email *

Phone Number *

H: HURT - Adequate pain control, including breathing ability, is first and foremost on the scale. Is the pet's pain successfully managed? Is breathing increased, rapid, labored or abnormal? Choose One *

1 (bad) 2 3 4 5 6 7 8 9 10 (good)

H: HUNGER - Is the pet eating enough? Does hand feeding help? Does the patient require a feeding tube? *

1 (bad) 2 3 4 5 6 7 8 9 10 (good)

H: HYDRATION - Is the patient dehydrated? *

1 (bad) 2 3 4 5 6 7 8 9 10 (good)

H: HYGIENE - Is the patient grooming themselves efficiently and/or maintaining general hygiene? The patient should be brushed and cleaned, particularly after elmination. Avoid pressure sores and keep all wounds clean. *

1 (bad) 2 3 4 5 6 7 8 9 10 (good)

H: HAPPINESS - 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? *

1 (bad) 2 3 4 5 6 7 8 9 10 (good)

M: MOBILITY - 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 slipping, falling or stumbling? *

1 (bad) 2 3 4 5 6 7 8 9 10 (good)

M: MORE GOOD DAYS THAN BAD - When bad days outnumber good days, quality of life might be compromised. *

1 (bad) 2 3 4 5 6 7 8 9 10 (good)

Quality of Life Total *

0-35 patient may be suffering, comfort care may not help preserve the quality of life of your pet >35 patient has an acceptable quality of life for considering home comfort care

Submit

Additional fees:
Same day/urgent visits, Extended travel, arrangements made outside business hours, aggressive pets

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home
Schedule an appointment
Contact us | Patient Form
Home Euthanasia
Hospice consultation
About Dr. Curtis
Services
Grief Support