Pets Name
(Required)
Owner Surname
(Required)
Phone
Email
(Required)
Pain Inventory
Which number that best describes the pain at its worst in the last 7days.
(0 = No Pain , 10 = Extreme Pain)
Which number that best describes the pain at its least in the last 7 days
(0 = No Pain , 10 = Extreme Pain)
Which number that best describes the pain at its average in the last 7 days.
(0 = No Pain , 10 = Extreme Pain)
WHich number that best describes the pain as it is right now.
(0 = No Pain , 10 = Extreme Pain)
Description of function:
Pick the position or number that best describes how during the last 7 days pain has interfered with your dog's: (0 = Does not interfere , 10 = Compolete Interfers)
General Activity
(0 = Does not interfere , 10 = Compolete Interfers)
Enjoyment of Life
(0 = Does not interfere , 10 = Compolete Interfers)
Ability to Rise to Standing From Lying Down
(0 = Does not interfere , 10 = Compolete Interfers)
Ability to Walk
(0 = Does not interfere , 10 = Compolete Interfers)
Ability to Run
(0 = Does not interfere , 10 = Compolete Interfers)
Ability to Climb Stairs, Curbs, Doorsteps, etc.
(0 = Does not interfere , 10 = Compolete Interfers)
Overall Quality of Life
Fill in the oval next to the one number that best describes your dog's overall quality of life over the last 7 days.
Overall Impression
(Required)
Poor
Fair
Good
Very Good
Excellent
Calculated Pain Score
Dont change this value it is calculated from previous selections.
Comments
This field is for validation purposes and should be left unchanged.
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