Pet Hospice Questionnaire for Happy Earth Pet Hospice

Thank you for taking the time to complete this questionnaire. The information you share helps me better understand your pet’s unique needs, daily routines, health concerns, and the loving bond you share. These details allow us to create a personalized hospice care plan that truly honors your pet and supports your family.

There are no right or wrong answers; just your perspective, your observations, and your heart. If there’s anything you’re unsure of, it’s okay to leave it blank or share more during our consultation.

Hospice Questionnaire
Name
Name
First
Last

Patient Information

Species
Sex
Spayed/Neutered

Maximum file size: 52.43MB

Veterinarian

Please answer the following questions based on how your pet has been feeling in the last 48-72 hours.

Energy Level
Energy is highest
My pet is: (please check all that apply)
My pet sleeps
Dreams
Mobility Level
My pet has a specific leg that seems to bothers him/her. Please check all that apply
Does weather seem to make your pet’s mobility worse. Please select all that apply.
Does your pet’s mobility seem better or worse after exercise?
Does your pet’s mobility seem better or worse after rest?
Does your pet like to seek warm areas including the sun?
Does your pet like to seek cool areas such as under a tree, on tiled flooring or by A/C vents?
Does your pet pant?
What is your pet's drinking habits?
What is your pet's urination habits?
When your pet is feeling 100%, is he/she a passionate eater?
Is your pet’s current appetite
Does your pet eat any of the following? Check all that apply
Does your pet vomit?
Is your pet’s stool
Does your pet have the following concerns with defecation (Check all that apply)
Please take a look at your pet’s skin and check all that apply
Please select how itchy your pet has been in the last 48 hours
If your pet is itchy, is there a time of day that seems to be the most intense
In reference to your pet’s respiration, please check all that apply
children petting their senior dog