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 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 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 Overall impression: 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 Email Mobile Phone Time's up
