Colorado Center For Animal Pai

4750 W. 120th AVE SUITE 400
WESTMINSTER, CO 80020

(720)502-5823

coanimalpaincenter.com

Canine Pain Questionnaire Form

Patient (required)

Owner's Name (required)
First Name (required)
Last Name (required)
Date (required) :
Does your dog greet you enthusiastically?
Yes
No
Does your dog have difficulty climbing stairs?
Yes
No
Does your dog need assistance in getting onto the bed or couch?
Yes
No
Does your dog need assistance jumping into the car?
Yes
No
Have your dog's eating habits changed?
Yes
No
If yes, please describe

Does your dog look relaxed when he/she is at rest?
Yes
No
Or does he/she have muscle twitches, stiffness, uncomfortable, unable to sit still?

Is your dog losing muscle tone/mass?
Yes
No
Does your dog tire more easily when going for walks?
Yes
No
Does your dog have a change in bladder and /or bowel habits?
Yes
No
Does your dog exhibit any changes in posture and/or expression?
Yes
No
Does your dog have a change in temperament?
Yes
No
Please explain.

Do you notice any behavioral changes that may indicate to you that your dog is in pain?
Yes
No
Please explain

Does your dog show signs of lameness?
Yes
No
What food are you feeding your dog?

How long has your dog shown signs of discomfort?

What medication/s is your pet currently taking?

What over the counter / supplements is your pet currently taking?

Most current blood work and / or diagnostic xrays?

DIAGNOSIS?

Regular Veterinarian/Veterinary Hospital


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