Quality of Life Survey for the Canine Cancer Patient

Dear Canine Cancer Patient Owner/Guardian, We really appreciate that you are taking time to complete the questionnaire about your dog’s well-being and health related quality of life. This will help us assess your dog’s 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. INFORMATION ABOUT YOUR DOG'S QUALITY OF LIFE ABOUT YOUR DOG NOW: 1. How much is your dog bothered by the cancer? a. Not at all, b. Somewhat, c. Moderately, d. A lot, e. Extremely 2. Does your dog still enjoy his favorite activity? a. Always, b. Often, c. Sometimes, d. Seldom, e. Never 3. Did you notice any changes in your dog's sleeping/resting patterns? a. None, b. Minimal, c. Moderate, d. A lot, E. Extreme 4. Your dog's behavior towards you is: a. Friendly, easily excited, b. Friendly, alert c. Mostly friendly, appropriate, d. Passive, indifferent, e. Aggressive 5. Your dog's appetite now is: a. Excellent b. Very good, c. Good, d. Fair, e. Poor 6. Your dog's quality of life now is: a. Excellent b. Very good, c. Good, d. Fair, e. Poor 7. Your dog's playfulness and activity level now is: a. Excellent b. Very good, c. Good, d. Fair, e. Poor

1

Quality of Life Survey for the Canine Cancer Patient
8. Your dog has signs of illness now: a. Never, b. Seldom, c. Sometimes, d. Often, e. Always 9. Your dog experiences pain/discomfort now: a. Never, b. Seldom, c. Sometimes, d. Often, e. Always 10. Your dog's enjoyment of human interaction now: a. Always, b. Often, c. Sometimes, d. Seldom, e. Never 11. Your dog is happy according to you: a. Always, b. Often, c. Sometimes, d. Seldom, e. Never 12. How often does your dog experience signs of anxiety and fear (shivering, increased salivation, panting, whimpering, howling, barking and growling) during your visits to MSU VTH? a. Never, b. Seldom, c. Sometimes, d. Often, e. Always 13. How often does your dog experience mobility problems (stiffness, limping, difficulty to stand up, increased resting) a. Never, b. Seldom, c. Sometimes, d. Often, e. Always

B. 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 chemotherapy’s administration and side effects (weakness, anorexia, nausea, vomiting) 2. Your pet’s QOL 3.Urinating/defecating/vomiting Somewhat Moderately A lot Extremely

2

Quality of Life Survey for the Canine Cancer Patient
in the house 4. Financial concerns 5. Perceptions of others about me seeking advanced care for my pet 6. Time concerns and scheduling visits 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!

3

Sign up to vote on this title
UsefulNot useful