Pain Assessment Form Please fill out this form and we will get in touch with you shortly.Name First Last Phone NumberE-mail Patient NameDate MM slash DD slash YYYY Rate your pet’s pain:1. Check the box next to the one number that best describes the pain at its WORST in the last 7 days: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 2. Check the box next to the one number that best describes the pain at its LEAST in the last 7 days: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 3. Check the box next to the one number that best describes the pain at its AVERAGE in the last 7 days: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 4. Check the box next to the one number that best describes the pain as it is right now: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme Description of Function:5. Check the boxl that best describes how in the last 7 days, the pain has interfered with your pet’s GENERAL ACTIVITY: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 6. Check the box that best describes how in the last 7 days, the pain has interfered with your pet’s ENJOYMENT OF LIFE: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 7. Check the box that best describes how in the last 7 days, the pain has interfered with your pet’s ABILITY TO RISE FROM LYING DOWN: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 8. Check the box that best describes how in the last 7 days, the pain has interfered with your pet’s ABILITY TO WALK: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 9. check the box that best describes how in the last 7 days, the pain has interfered with your pet's ABILITY TO RUN: 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme 10. Check the box that best describes how in the last 7 days, the pain has interfered with your pet’s ABILITY TO CLIMB UP (stairs, curbs, etc): 0-no pain 1 2 3 4 5 6 7 8 9 10-extreme Overall Impression:11. Check the box next to the oval that best describes your pet’s overall quality of life over the last 7 days: Poor Fair Good Very Good Excellent
