Canine Brief Pain Inventory - Kalinga Park Veterinary Surgery

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Welcome to your Pain Assessment Questionnaire

Select the one number that best describes the pain at its worst in the last 7 days.
0 is none, 10 is extreme

0 1 2 3 4 5 6 7 8 9 10

Select the number that best describes the pain at its least in the last 7 days (0 is none , 10 is extreme pain)

0 1 2 3 4 5 6 7 8 9 10

Select the number that best describes the pain at its average in the last 7 days.

0 1 2 3 4 5 6 7 8 9 10

Select the number that best describes the pain as it is right now

0 1 2 3 4 5 6 7 8 9 10

0 = doesnt intefer , 10 = completely interfers

Fill in the oval next to the one number that best describes how during the last 7 days pain has interfered with your dog's:

General Activities

0 1 2 3 4 5 6 7 8 9 10

Enjoyment of Life

0 1 2 3 4 5 6 7 8 9 10

Ability to Rise to Standing From Lying Down

0 1 2 3 4 5 6 7 8 9 10

Ability to Walk

0 1 2 3 4 5 6 7 8 9 10

Ability to Run

0 1 2 3 4 5 6 7 8 9 10

Ability to Climb Stairs, Curbs, Doorsteps, etc

0 1 2 3 4 5 6 7 8 9 10

Select number that best describes your dog's overall quality of life over the last 7 days

0 1 2 3 4 5 6 7 8 9 10

Fill in the captcha

Please enter any other notes you might have regarding your Pet's condition

Patient Name

Client Name

Mobile Phone

Time is Up!

Time's up

The Canine Brief Pain Inventory (Canine BPI; www.CanineBPI.com ) copyright is held
by Dr. Dorothy Cimino Brown