Canine Cushing’s Quality-of-Life Survey
Help us assess your dog’s well-being while living with Cushing’s disease.
Owner’s Full Name
*
First Name
Last Name
Owner’s Email Address
*
example@example.com
Dog’s Name
*
Dog’s Age (in years)
*
Dog’s Breed
Dog’s Sex
*
Male
Female
Neutered/Spayed
Other
How long ago was your dog diagnosed with Cushing’s disease?
*
Please Select
Less than 3 months
3–6 months
6–12 months
Over 1 year
Not sure
Is your dog currently receiving medication or treatment for Cushing’s disease?
*
Yes
No
Please rate the frequency or severity of the following symptoms your dog has experienced in the past month:
*
Rows
Never
Rarely
Sometimes
Often
Always
Increased thirst/drinking
1
2
3
4
5
Increased urination
6
7
8
9
10
Increased appetite
11
12
13
14
15
Panting
16
17
18
19
20
Lethargy or tiredness
21
22
23
24
25
Weakness or muscle loss
26
27
28
29
30
Hair loss or skin changes
31
32
33
34
35
Pot-bellied appearance
36
37
38
39
40
Restlessness or anxiety
41
42
43
44
45
How would you rate your dog’s overall quality of life in the past month?
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Please share any additional comments about your dog’s health or well-being:
Submit Survey
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