Owner Name
Email
Phone Number
Pet Name
Sex
Ages
How severe and disturbing has your pet’s disease been? (not at all/a little/quite a bit/very much)
What was the impact of your pet’s disease on its behaviour and/or mood? (More lazy, nervous, and/or aggressive, etc) (Not at all/a little/quite a bit/very much)
How much was your pet’s sleeping patterns disturbed by the disease? (Not at all/a little/quite a bit/very much)
How much were your pet’s meals disturbed by the disease? (It has no appetite, it scratches during meals, it does not like special food,etc) (Not at all/a little/quite a bit/very much)
How much was your pet’s playing or working activities disturbed by the disease? (It is more lazy, nervous, itchy) (Not at all/a little/quite a bit/very much).
What was the impact of your pet’s disease on its relationship to you, other family members, or other pets? (Due to mood changes, presence of skin lesions,etc) (Not at all/a little/quite a bit/very much).
How much has your pet’s disease changed its usual habits? (Change in place where he is allowed to sleep, live, eat, way in which it is walked, etc) (Not at all/a little/quite a bit/very much).
How much time did you lose for your pet’s disease? (Administration of therapies, shampooing, home cleaning, cooking, veterinary consultations, etc) (Not at all/a little/quite a bit/very much).
How much time did you lose for your pet’s disease on your tiredness? (Extra cleaning, cooking, shampooing, etc) (Not at all/a little/quite a bit/very much).
How much impact did your pet’s disease have on your expenditure? (Cost of treatment, veterinarian, etc) (Not at all/a little/quite a bit/very much)
How much effect did your pet’s disease have on causing emotional distress (Feelings of guilt, powerlessness, sorrow, regret, anxiety, nuisance, disgust, anger, frustration, etc) (Not at all/a little/quite a bit/very much).
How much physical uneasiness/discomfort did you experience due to your pet’s disease (Offending odour, feeling of dirtiness at home, aesthetic nuisance, etc) (Not at all/a little/quite a bit/very much).
How much impact did your pet’s disease have on the relationship between family members? (Between spouses, parents and children, relatives and friends, etc) (Not at all/a little/quite a bit/very much)
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