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Dear Canine Cancer Patient Owner/Guardian, We really appreciate that you are taking time to complete the questionnaire about your dogs well-being and health related quality of life. This will help us assess your dogs quality of life. All your answers will be treated with the strictest confidence. Please observe the Instructions below: Only one owner, the person with whom the dog relates mostly should answer the questions and they should do so on their own. Read each question carefully, if you do not know the answer, please indicate so, by writing: Don't know. 1. Have you had your dog since he/she was a puppy? Yes __ No__ 2. If not, how many years ago did you adopt it? ____ A) BEHAVIOR OF YOUR DOG 6 MONTHS BEFORE ANY SIGNS OF DISEASE: Please circle the one that applies most: (This part of the questionnaire was used in order to establish baseline of QOL for the individual animal) ABOUT YOUR DOG 6 MONTHS BEFORE: 1. Your dog's behavior towards you was: a. Friendly, easily excited, b. Friendly, alert c. Mostly friendly, appropriate, d. Passive, indifferent, e. Aggressive 2. Your dog's activity level in the past: a. Very active, b. Somewhat active c. Average, d. Reduced, e. Poor 3. Your dog's appetite in the past: a. Excellent b. Very good, c. Good, d. Fair, e. Poor 4. Your dog's overall quality of life in the past was: a. Excellent b. Very good, c. Good, d. Fair, e. Poor 5. Your dog's playfulness and activity level in the past was: a. Excellent b. Very good, c. Good, d. Fair, e. Poor 6. Your dog had signs of illness in the past: a. Never, b. Seldom, c. Sometimes, d. Often, e. All the time
14. Things that your dog enjoyed (please circle all that applies): Food Human-animal interaction Staying at home Car ride Walking All of them Play Exercise Other
C. INFORMATION ABOUT YOU DURING THAT STRESSFUL PERIOD OF YOUR LIFE ABOUT YOURSELF NOW: 1. How worried are you about your dog's illness? a. Not at all, b. Somewhat, c. Moderately, d. A lot, e. Extremely 2. Rate the amount of worry each of these are causing you: Potential Factors Not at all 1. The chemotherapys administration and side effects (weakness, anorexia, nausea, vomiting) 2. Your pets QOL 3.Urinating/defecating/vomiting in the house 4. Financial concerns 5. Perceptions of others about me seeking advanced care for my pet 6. Time concerns and scheduling visits Somewhat Moderately A lot Extremely
3. Please rank how much of a limitation your animal's current condition is to your regular activities: a. Not at all, b. Somewhat, c. Moderately, d. A lot, e. Extremely
D. EVALUATION OF OUR SURVEY: 1. How easy was for you to complete the questionnaire? a. Extremely easy, b. Very easy, c. Moderately easy, d. Somewhat easy, e. Not at all 2. Did you like this opportunity to do this survey in order to evaluate your dog's situation? a. Very much, b. Quite a bit, c. Moderately, d. Somewhat, e. Not at all 3. Please comment on how this survey can be improved: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
This is the end of the survey. Thank you for completing the QOL questionnaire!