Please print this form before hitting the submit button. Hospice Care Instructions This form is not needed if the sole purpose of the visit if for a Euthanasia. This form is only needed if you are requesting a Quality of Life assessment or a Hospice visit. Having accurate background medical history on your pet is extremely important in order for the doctor to help you assess your pet's Quality of Life and devising a hospice care plan. Filling out this form as completely and as accurately as possible will streamline the hospice consultation and will help the doctor gather valuable medical history about your pet which will lead to the consultation time being spent on discussing important concerns you have about your pet and his Quality of Life rather than spending time gathering the medical history. Please give us as many details as you can. Pet owner information Owner name Address Address 2 City/Town State ZIP Email Phone Cell Information about your pet Pet's name Sex - Select -MaleFemaleNeutered MaleSpayed Female Breed DOB or age Weight Description (color, markings) Veterinarian Primary Veterinarian Primary veterinarian phone number Any other veterinarians in last 2 years Update your veterinarian? Yes No As a courtesy, Home Pet Euthanasia will update your veterinarian on the visit and course of treatment of your pet so that they may update their records and advise us of any diagnosis or tests that may be relevant to your pet's hospice care or choice of medication. Who referred you to us? YELP Google Facebook Used your services before Friend referral Veterinarian Other, from internet Other Please specify Note The information you will provide about your pet will help us greatly on deciding on the course of action that will be most beneficial for your pet and your family.Please answer the following questions as accurately as possible. Hospice visit Primary reason for hospice visit When did you first observe symptoms? Symptoms Symptoms On a scale of 0 (none) to 5 (extreme), please rate each of these symptoms Questions 0 1 2 3 4 5 Vomiting 0 1 2 3 4 5 Diarrhea 0 1 2 3 4 5 Constipation 0 1 2 3 4 5 Coughing 0 1 2 3 4 5 Sneezing 0 1 2 3 4 5 Skin conditions (itching, hair loss, redness, etc...) 0 1 2 3 4 5 Seizures (frequency,duration) 0 1 2 3 4 5 Excessive drinking 0 1 2 3 4 5 Excessive urinating 0 1 2 3 4 5 Urine Incontinence 0 1 2 3 4 5 Fecal incontinence 0 1 2 3 4 5 Accidents 0 1 2 3 4 5 Limping 0 1 2 3 4 5 Dementia 0 1 2 3 4 5 Lack of appetite 0 1 2 3 4 5 Excessive appetite 0 1 2 3 4 5 Weight loss 0 1 2 3 4 5 Weight gain 0 1 2 3 4 5 Halitosis (foul breath) 0 1 2 3 4 5 Comments Medical information Was your pet diagnosed with any particular condition(s)? If so, by whom? What tests were done? Please attach any laboratory results or diagnostics results if you are able to obtain them with any doctor comments. If possible, please have the full medical record faxed over ahead of time so that the doctor can review your pet’s condition in details. What treatments has he received for these conditions? Please describe any treatments such as medication, chemo, radiation, surgeries, etc... What has the response to the treatment been? Please give details on response to treatment, medication reactions, improvements, etc... What medication is your pet currently on? Please list all medication and neutraceuticals your pet is currently receiving, as well as the dose and frequency Has your pet had any adverse reactions to ANY medication? List any medication reactions your pet has ever had in his life. Give the name of the medication, what happened and when it was. What is your pet's current diet? Enter any dry food, canned food as well as any table foods and treats. What are your pet's favorite foods? Quality of Life note Please fill out the Quality of Life test: Quality of Life Scale: The HHHHHMM Scale? Hurt - Select -12345678910 Adequate pain control, including breathing ability, is of top concern. Trouble breathing outweighs all concerns. Is the pet's pain successfully managed? Can the pet breathe properly? Is oxygen supplementation necessary? Please note that 1 is unbearable pain and 10 is no pain at all Hunger - Select -12345678910 Is the pet eating enough? Does hand feeding help? Does the patient require a feeding tube? Hydration - Select -12345678910 Is the patient dehydrated? For patients not drinking enough, use subcutaneous fluids once or twice daily to supplement fluid intake. Hygiene - Select -12345678910 The patient should be brushed and cleaned, particularly after elimination. Avoid pressure sores and keep all wounds clean. Happiness - Select -12345678910 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? Mobility - Select -12345678910 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 having seizures or stumbling? (Some caregivers feel euthanasia is preferable to amputation, yet an animal who has limited mobility but is still alert and responsive can have a good quality of life as long as caregivers are committed to helping the pet.) More good days than bad - Select -12345678910 When bad days outnumber good days, quality of life might be compromised. When a healthy human-animal bond is no longer possible, the caregiver must be made aware the end is near. The decision for euthanasia needs to be made if the pet is suffering. If death comes peacefully and painlessly at home, that is okay. Total Pet care givers can use this scale to help assess and monitor pet quality of life and hospice care. Score patients using a scale of 1 to 10. Please note that a score of 10 would mean a perfect condition. For example in the case of pain, 10 means NO pain at all, jumping and running like a 2 year old healthy pet, whereas a 1 would mean the pet is in extreme pain. For hunger, a score of 10 means excellent appetite and eating very well. What are your considerations regarding your pet's Quality of Life? What family members are most involved in your pet's care? What other family pets interact with your pet? Who are your pet's best friends? Whose company does your pet enjoy the most? How does your pet's condition affect YOUR quality of life? Pain indicators Please fill out the pain indicator list below. It is recommended that, when assessing your pet's pain, you rate each indicator below with a score from 0-10 (0 being that the symptom is absent and 10 being maximum manifestation of the symptom). Please see the "Home tests" page where you will find the list in a table format ready to print and check off each symptom. Keeping track of these symptoms and how their intensity varies throughout the course of the disease your pet has will help you monitor the progress and the success of any pain management being conducted. Pain indicators list Questions 1 2 3 4 5 6 7 8 9 10 N/A 1. Droopy head 1 2 3 4 5 6 7 8 9 10 N/A 2. Droopy ears 1 2 3 4 5 6 7 8 9 10 N/A 3. Tucked tail 1 2 3 4 5 6 7 8 9 10 N/A 4. Does not want to play 1 2 3 4 5 6 7 8 9 10 N/A 5. Lack of social interaction 1 2 3 4 5 6 7 8 9 10 N/A 6. Does not enjoy games 1 2 3 4 5 6 7 8 9 10 N/A 7. Subtle lack of alertness gradually increasing to a deep apathy (early sign will be subtle) 1 2 3 4 5 6 7 8 9 10 N/A 8. Diminished appetite 1 2 3 4 5 6 7 8 9 10 N/A 9. Body tension 1 2 3 4 5 6 7 8 9 10 N/A 10. Facial tension 1 2 3 4 5 6 7 8 9 10 N/A 11. Accepting treats or food gingerly (particularly if pet used to accept them enthusiastically) 1 2 3 4 5 6 7 8 9 10 N/A 12. Lack of interest in walks 1 2 3 4 5 6 7 8 9 10 N/A 13. Doesn't respond when called 1 2 3 4 5 6 7 8 9 10 N/A 14. Worried or sad facial expression 1 2 3 4 5 6 7 8 9 10 N/A 15. Ears pulled back or flattened 1 2 3 4 5 6 7 8 9 10 N/A 16. Eyes wide open to expose “white of the eye” 1 2 3 4 5 6 7 8 9 10 N/A 17. Avoidance of direct eye contact 1 2 3 4 5 6 7 8 9 10 N/A 18. Lips may be retracted, exposing the teeth in a submissive grin (dogs) 1 2 3 4 5 6 7 8 9 10 N/A 19. Almond shaped eyes (caused by facial tension) 1 2 3 4 5 6 7 8 9 10 N/A 20. Whiskers pulled back against cheeks (caused by facial tension) 1 2 3 4 5 6 7 8 9 10 N/A 21. Uncomfortable when resting 1 2 3 4 5 6 7 8 9 10 N/A 22. Shifts frequently when resting 1 2 3 4 5 6 7 8 9 10 N/A 23. Head held abnormally low 1 2 3 4 5 6 7 8 9 10 N/A 24. Difficulty getting up 1 2 3 4 5 6 7 8 9 10 N/A 25. Excessive panting (particularly when it is not hot) 1 2 3 4 5 6 7 8 9 10 N/A 26. Shivering/trembling/shaking 1 2 3 4 5 6 7 8 9 10 N/A 27. Unsettled 1 2 3 4 5 6 7 8 9 10 N/A 28. Pacing 1 2 3 4 5 6 7 8 9 10 N/A 29. Difficulty moving after a long rest 1 2 3 4 5 6 7 8 9 10 N/A 30. Difficulty lying down 1 2 3 4 5 6 7 8 9 10 N/A 31. Slow or unusual gait 1 2 3 4 5 6 7 8 9 10 N/A 32. Limping 1 2 3 4 5 6 7 8 9 10 N/A 33. Hunched back 1 2 3 4 5 6 7 8 9 10 N/A 34. Compulsive licking or rubbing of a certain body part 1 2 3 4 5 6 7 8 9 10 N/A 35. Looking at sides or other body part suddenly and/or worriedly 1 2 3 4 5 6 7 8 9 10 N/A 36. Suddenly running away from “nothing in particular” 1 2 3 4 5 6 7 8 9 10 N/A 37. Can't jump on couch or bed 1 2 3 4 5 6 7 8 9 10 N/A 38. Reluctance to lie down 1 2 3 4 5 6 7 8 9 10 N/A 39. Sleeps in a position that avoids a certain body part from touching the ground or bed 1 2 3 4 5 6 7 8 9 10 N/A 40. Any change in normal sleep patterns 1 2 3 4 5 6 7 8 9 10 N/A 41. Purplish tongue color (NOT gums: tongue) 1 2 3 4 5 6 7 8 9 10 N/A 42. ”Guards” a particular body part 1 2 3 4 5 6 7 8 9 10 N/A 43. Reluctance to be touched in a certain area 1 2 3 4 5 6 7 8 9 10 N/A 44. Reluctance to be picked up 1 2 3 4 5 6 7 8 9 10 N/A 45. Lying down at a distance from everybody and somewhat isolated 1 2 3 4 5 6 7 8 9 10 N/A 46. Disinterested in surroundings 1 2 3 4 5 6 7 8 9 10 N/A 47. Unusual attention seeking 1 2 3 4 5 6 7 8 9 10 N/A 48. Flinching when touched in a certain area 1 2 3 4 5 6 7 8 9 10 N/A 49. Doesn't rest easily when lying down 1 2 3 4 5 6 7 8 9 10 N/A 50. Aggressive behavior to protect a particular area 1 2 3 4 5 6 7 8 9 10 N/A 51. Aggressive behavior on a usually docile pet 1 2 3 4 5 6 7 8 9 10 N/A 52. Crying when a particular area is touched 1 2 3 4 5 6 7 8 9 10 N/A 53. Wakes up at night 1 2 3 4 5 6 7 8 9 10 N/A 54. Does not sleep well 1 2 3 4 5 6 7 8 9 10 N/A 55. Refusal to go on walks 1 2 3 4 5 6 7 8 9 10 N/A 56. Moaning 1 2 3 4 5 6 7 8 9 10 N/A 57. Whimpering 1 2 3 4 5 6 7 8 9 10 N/A 58. Refusing to eat 1 2 3 4 5 6 7 8 9 10 N/A 59. Pressing head against wall (if head pain is present) 1 2 3 4 5 6 7 8 9 10 N/A 60. Unable to get up 1 2 3 4 5 6 7 8 9 10 N/A 61. Crying in pain 1 2 3 4 5 6 7 8 9 10 N/A 62. Teeth clenched, biting down on an object (particularly cats) 1 2 3 4 5 6 7 8 9 10 N/A 63. Howling/screaming uncontrollably 1 2 3 4 5 6 7 8 9 10 N/A What are your expectations regarding your pet's hospice? Tell us about your religious/spiritual beliefs Do you have religious/spiritual beliefs that you wish us to know about and which should be taken into consideration during your pet’s hospice care and/or euthanasia? Telling us about your beliefs will help us honor and respect them. Anything else you would like to communicate? Please feel free to say as much as you like. Agreement Note Your pet’s hospice care is a matter we take to heart. We will do our very best to ensure that your pet has the most comfortable End of Life experience possible. Caring for a terminal pet can be time consuming and requires a commitment both on your part and on our part. Therefore communication between doctor and pet parent it is of prime importance. For routine updates, please email the doctor. You can send your email at [email protected] and our staff will forward your email to the doctor who has seen your pet. For urgent matters, you can contact us via phone at 714-454-4080. Do not use text messages under any circumstance. In the case of urgent matters, it is possible that you may speak to a different doctor than the one who did the original hospice consultation, depending on who is on call at the time. For prescription refills, please contact the doctor via email (as per above) at least 3 days in advance. For refill authorizations of prescriptions, you may be required to repeat the Quality of Life scale, the pain indicators table as well as give us an update on how your pet is doing so that we may adjust the dosage and prescriptions in your pet’s best interest. The first consultation fee includes a one hour consultation in your home and one month of email follow-ups. Over-the-phone follow-ups are subject to a fee of $125/15 minutes. Follow-up hospice (not euthanasia) visits within one month of the original visit are offered at a discount (excluding any applicable travel and off hours fee). An update on Quality of Life scale and pain table are required to benefit from discounted fee on monthly visits. A fee of $150 per month will be assessed for email follow ups after the first month. This fee will be waived if a follow-up home visit is made within one month of original visit. We have 5 amazing doctors in our team. Each doctor was chosen for her exceptional compassion and caring. Due to our doctors' schedules (both personal and professional), it may not be possible for the same doctor who attended your pet's hospice visit(s) to be the one helping you with your pet's euthanasia. Rest assured that your pet, you and your family will be treated with the utmost compassion regardless of which doctor helps you during the course of your pet's hospice and euthanasia. I understand and agree to the above terms and conditions Signature Enter your name as signature Date
