Pet & Owner Information
Please describe your dog's pain on the following scale:
0 = No Pain
10 = Extreme Pain
Which number best describes your dog's pain at its WORST in the last 7 days?
Which number best describes your dog's pain at its LEAST in the last 7 days?
Which number best describes the AVERAGE pain level your dog's been experiencing?
Which number best describes your dog's pain RIGHT NOW?
Description of Function
Please rate how pain has interfered with these aspects of your dog's life based on the following scale
0 = No Interference
10 = Completely Interferes
General Activity
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:
Fill in the oval next to the one number that best describes your dog's overall quality of life over the last 7 days.
Please complete the questions in this section pertaining to your pet’s functional abilities to help us in monitoring progress based on the following scale:
1 = Not able to perform this activity (needs assistance 100% of the time)
2 = Moderate assistance needed to perform activity (needs assistance more than 50% of the time)
3 = Minimal assistance needed to perform activity (needs assistance less than 50% of the time)
4 = Independent with activity (no assistance needed)
N/A = Not applicable
Able to position to urinate?
Able to position to defecate?
Able to transfer from lying to sitting & vice versa?
Able to transfer from lying to standing & vice versa?
Able to transfer from sitting to standing & vice versa?
Able to roll over?
Able to scratch behind ears?
Able to ascend stairs?
Able to descend stairs?
Able to walk up an incline/hill?
Able to get in and out of your car?
Able to run?
Able to jump?
Is she/he able to do that activity?
Is your pet able to go on a walk?
Has your pet’s ability to take walks changed at all?
Do you notice any problems (limping, stiffness) or are those problems worse after taking a walk or exercise?
Does your pet tire quickly, have to make rest stops, or lap behind during walks?
Does your pet seem to be in pain?
Are there any other problems that you have noticed that have not been covered on this form?
Select yes or no for each of the following:
My dog is licking at one area obsessively
My dog’s appetite has decreased
My dog does not get up to greet me any longer:
My dog sleeps more
My dog is restless at night
My dog does not want to go for walks any more or lags behind on walks
My dog has always been housebroken, but now is having accidents in thehouse:
My dog does not want to be touched or pet:
My dog is newly reactive or aggressive toward people or other animals:
My dog is limping or not putting weight on a leg:
My dog can’t seem to get comfortable:
My dog struggles to go up or down stairs:
My dog has trouble getting up from laying down:
My dog does not sniff or smell during walks, instead is panting heavily:
My dog is trembling, pacing or circling:
My dog can no longer jump in the car or on the couch:
My dog has a glazed or wide-eyed look:
My dog’s ears are pinned back
My dog pants a lot, even at rest:
My dog’s coat seems dull, and the hair stands up in places:
My dog no longer wants to be held or picked up:
My dog is reclusive and hiding
My dog’s back is hunched:
My dog does not want to turn his head or move his neck:
My dog is whimpering, moaning or yelping:

If you answered YES to any of these questions, your dog may be suffering from chronic pain. Arthritis is the most common cause of chronic pain and requires a multi-prong approach to treatment, including pain relievers.

It is crucial that your pet’s pain be addressed in order to minimize the long-term consequences of pain and preserve a good quality of life for them.

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