Pain Description

No Pain

Extreme Pain

Rate your dog’s pain:

1. Fill in the oval next to the one number that best describes the pain at its worst in the last 7 days (0 = no pain, 10 = extreme pain)

0    1    2    3    4    5    6    7    8    9    10

2. Fill in the oval next to the one number that best describes the pain at its least in the last 7 days (0 = no pain, 10 = extreme pain)

0    1    2    3    4    5    6    7    8    9    10

3. Fill in the oval next to the one number that best describes the pain at its average in the last 7 days (0 = no pain, 10 = extreme pain)

0    1    2    3    4    5    6    7    8    9    10

4. Fill in the oval next to the one number that best describes the pain as it is right now (0 = no pain, 10 = extreme pain)

0    1    2    3    4    5    6    7    8    9    10

5. 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 ACTIVITY (0 = does not interfere, 10 = completely interferes)

0    1    2    3    4    5    6    7    8    9    10

6. 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 ENJOYMENT OF LIFE (0 = does not interfere, 10 = completely interferes)

0    1    2    3    4    5    6    7    8    9    10

7. 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 ABILITY TO RISE TO STANDING FROM LYING DOWN (0 = does not interfere, 10 = completely interferes)

0    1    2    3    4    5    6    7    8    9    10

8. 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 ABILITY TO WALK (0 = does not interfere, 10 = completely interferes)

0    1    2    3    4    5    6    7    8    9    10

9. 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 ABILITY TO RUN (0 = does not interfere, 10 = completely interferes)

0    1    2    3    4    5    6    7    8    9    10

10. 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 ABILITY TO CLIMB STAIRS, CURBS, DOORSTEPS, ETC (0 = does not interfere, 10 = completely interferes)

0    1    2    3    4    5    6    7    8    9    10

11. Fill in the oval next to the one number that best describes your dog’s overall quality of life over the last 7 days

Poor

Fair

Good

Very Good

Excellent

Consider treating pain when total score is ≥30.