Name: Paws Into Grace
Telephone: +1-
Price range: $$

Owner's Name*
First Last
Email*
Phone*
Primary Contact - this will be the main person our Comfort Care Team will contact for updates*
First Last
Phone*
Email*
Pet's Name*
Species*
Breed*
Age*
Sex
Who is your pet's regular veterinarian?*
Has your pet seen any veterinary specialists or visited any emergency hospitals in the past year? If so, please list (we will attempt to collect all pertinent medical records prior to the appointment):
Has your pet had any recent lab panels? If so, please provide a copy of the results.
Max. file size: 8 MB.

Medical Information
What is the diagnosis or primary concern that prompted you to schedule an appointment with us?
How long has the problem been going on? Has it worsened recently, and if so, please describe:
Does your pet have any past medical problems or diagnoses that we should be aware of?
Has your pet had any surgeries in the past (beyond spay/neuter)?
What medications is your pet currently taking? Please list names of drugs, doses, and frequency if possible, as well as any over the counter or holistic supplements:
Has your pet been on other medications in the past that have helped the condition, or are there any medications your pet has reacted adversely to?
What type of food, and how much does your pet eat daily?

Quality of Life Tools
How is your pet’s appetite? Any changes?
Has there been any vomiting, diarrhea, increased urination or thirst?
Have there been any urinary or fecal accidents in the house (or outside the litter box for cats)?
Does your pet seem to realize if they need to go to the bathroom, or do they leak urine or feces without seeming to know it’s happening?
Has there been any coughing, sneezing, nasal discharge, or any difficulty/labored/rapid breathing?
Does your pet show any signs of pain?
In dogs, this can include panting, restlessness/pacing, lethargy, becoming less active, limping or stiff gait, difficulty rising, vocalization, flinching when painful areas are touched, becoming aggressive towards people and other pets, withdrawing from the family, etc. In cats, this can include hiding, vocalization, less interaction with people or other pets, reluctance to jump on/off furniture or use stairs, decreased grooming/poor hair coat, decreased appetite, limping or stiff gait, sitting in abnormal positions when at rest, squinted eyes, holding the chin in a tucked position, etc.
How is your pet's mobility/ability to get around? Does he/she require assistance to walk or go to the bathroom? Do you utilize tools such as a sling or harness to help you lift your pet?
Does your pet have trouble with various surfaces such as hard flooring or stairs? Is there anything in your environment that makes it challenging for your pet to get around?
What is your pet’s typical activity level (i.e. mellow couch potato vs. energetic athlete)? Has that changed recently?
What is your pet’s temperament? Have they ever had a history of aggression, fear, or any other concerns with strangers?
Does your pet generally do well with examinations and/or shots at the vet? Has your vet ever needed to use a muzzle or sedatives to evaluate or handle your pet?

Home Dynamics
Who is the caregiver for your pet?
How much time does your pet spend unattended each day? Does this cause any difficulties in providing care?
Is your pet primarily indoors, outdoors, or a mixture of both?
Are there young children or other pets in the household, and if so, do these present challenges in caring for your pet?
Are there any physical, emotional, or time constraint difficulties that you’d like to share with us that are making it challenging to care for your pet?

Goals for Hospice
What is the primary goal you have in meeting with us (prepare for end of life, help with comfort care, help with evaluating current quality of life, etc)?
Are there any specific questions that you have that we can help answer?
Would you like to be contacted about additional grief support to help you through this difficult time?
Would you be interested in additional testing and treatment if the doctor feels that it is an option, or are you focused more on palliative care for your pet?
Is anyone in your family struggling with making decisions about care or euthanasia for your pet, or do you feel that you are “on a different page” than other family members?
Do you have a belief system that supports your wishes for your pet’s end of life journey? How can we help you honor this?
Have you envisioned your pet’s ideal passing? People that will be present, location, special blankets, music, etc. If you have specific ideas and wishes please let us know so we can try our best to help your pet cross over peacefully and comfortably:

Medical History Form

Medical History 2023 Revision

Step 1 of 5

Medical Information

Quality of Life Tools

Home Dynamics

Goals for Hospice

Testimonials

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