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WORK HOURS:

Monday - Friday 9am - 5pm

Sleaford, United Kingdom

OUR LOCATION

Veterinary Acupuncture and Pain Management

Canine Brief Pain Inventory

Please use this form to provide us with the detail of your dogs pain score.

Date

Description of pain

Rate your dog's pain:

1. Select one number that best describes the pain at its worst in the last 7days.
0 - No Pain
1
2
3
4
5
6
7
8
9
10 - Extreme Pain
2. Select 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 Pain
3. Select 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 Pain
4. Select 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 Pain

Description of function:

Select one number that best describes how during the last 7 days pain has interfered with your dog's:

5. General Activity
0 - Does not interfere
1
2
3
4
5
6
7
8
9
10 - Completely interferes
6. Enjoyment of Life
0 - Does not interfere
1
2
3
4
5
6
7
8
9
10 - Completely interferes
7. Ability to Rise to Standing From Lying Down
0 - Does not interfere
1
2
3
4
5
6
7
8
9
10 - Completely interferes
8. Ability to Walk
0 - Does not interfere
1
2
3
4
5
6
7
8
9
10 - Completely interferes
9. Ability to Run
0 - Does not interfere
1
2
3
4
5
6
7
8
9
10 - Completely interferes
10. Ability to Climb Stairs, Curbs, Doorsteps, etc.
0 - Does not interfere
1
2
3
4
5
6
7
8
9
10 - Completely interferes

Overall Impression:

11. Select 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
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To fill out the online Canine Brief Pain Inventory Form, please ensure all required fields are completed with accurate personal and pet information.


Thank you for completing the form online.

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