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

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

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

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

1 out of 3

Description of function:




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

Enjoyment of Life

Ability to Rise to Standing From Lying Down

Ability to Walk

Ability to Run

Ability to Climb Stairs, Curbs, Doorsteps, etc

Overall impression:


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

2 out of 3
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3 out of 3
Patient Name
Client Name
Email
Mobile Phone

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