Exercise & Pain Information
Owner Questionnaire for dogs with mobility problems.
Owner Name
First Name
Last Name
Pets Information
Name
Breed
Age
Sex
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Background
1. How Long has your pet been suffering with his/her mobility problem?
0-6 months
6-12 months
12-24 months
24-36 months
More then 36 months
Select one
2. Has your dog been diagnosed as suffering from any other problems in addition to his/her orthopaedic disease?
Yes
No
Select one
If yes, please list these if you can:
3. If you can, please list any medications that your pet is currently receiving
Lifestyle
1. In the last week, on average, how far has your dog exercised each day?
0-0.6 miles
0.6-1.2 miles
1.2-1.9 miles
1.9-2.5 miles
More than 2.5 miles
Select one
2. In the last week, on adverage, how many walks has you dog had each day?
0
1
2
3
4
Select one
3. What type of Exercise is this?
Always on leash
Mostly on Leash
Mostly off leash
Always off leash
Working
Select one
4. Are there particular days of the week upon which your dog has significantly more exercise?
monday
Tuesday
wednesday
Thursday
Friday
Saturday
Sunday
Select as many as needed
5. On what sort of terrain does your dog most often exercise?
On level grass
In woodland
On street
Over Rough Ground
Select one
6. At exercise, how is your dog handled?
Walk on Leash
Walk off leash
Trot
Run freely
Select one
7. Who Limits the extent to which your dog exercises?
You
Your dog
Select one
Mobility
Generally
1. How is your dog's mobility in general?
Very good
Good
fair
Poor
Very Poor
Select one
2. How disabled is your dog by his/her lameness?
Not at all disabled
slightly disabled
moderately disabled
Severely Disabled
Extremely disabled
select one
3. How active is your dog
Extremely active
Very active
moderately active
Slightly active
Not at all active
Select one
4. What is the effect of cold, damp weather on your dog's lameness?
No effect at all
Mild effect
Moderate effect
Severe effect
Extreme effect
Select one
5. To what degree does your dog show stiffness in the affected leg after a "lie down"?
No stiffness
Mild Stiffness
Moderate Stiffness
Severe stiffness
Extreme stiffness
Select one
Mobility
At Exercise
6. During exercise, how active is your dog?
Extremely active
Very Active
Fairly Active
Not very Active
Not at all Active
Select one
7. How keen is your dog to exercise?
Extremely Keen
Very Keen
Fairly Keen
Not very Keen
Not at all Keen
Select one
8. How would you rate your dogs ability to exercise?
Very Good
Good
Fair
Poor
Very Poor
Select one
9. What overall effect does exercise have on your dogs lameness?
No effect
Mild effect
moderate effect
severe effect
Extreme effect
Select one
10. How often does your dog rest (stop/sit down) during exercise?
Never
Hardly ever
Occationally
Frequently
Very Frequently
Select one
11. What is the effect of cold, damp weather on your pet's ability to exercise?
No effect
Mild effect
moderate effect
Severe effect
Extreme effect
Select one
12. To what degree does your dog show stiffness in the affected leg after a "lie down" following exercise?
No stiffness
Mild stiffness
Moderate stiffness
Severe stiffness
Extreme stiffness
Select one
13. What is the effect of your dogs lameness on his/her ability to exercise?
No effect
Mild effect
Moderate effect
Severe effect
Extreme effect
Select one
Description of Pain
14. Rate your dogs pain to the best of your ability, that best describes the pain at its worst in the last 7days. On a scale of 0 - 5 with 0 being no pain and 5 extreme pain?
0
1
2
3
4
5
Select one
15. Rate your dogs pain to the best of your ability that best describes the pain as it is right now. On a scale of 0 - 5 with 0 being no pain and 5 extreme pain?
0
1
2
3
4
5
Select one
16. Ability to climb stairs, curbs, doorsteps etc On a scale of 0 - 5 with 0 Does not interfere and 5 completely interferes?
0
1
2
3
4
5
Select one
17. Ability to walk & run On a scale of 0 - 5 with 0 Does not interfere and 5 completely interferes?
0
1
2
3
4
5
Select one
18. General activity On a scale of 0 - 5 with 0 Does not interfere and 5 completely interferes?
0
1
2
3
4
5
Select one
19. Enjoyment of life On a scale of 0 - 5 with 0 Does not interfere and 5 completely interferes?
0
1
2
3
4
5
Select one
20. Ability to rise to standing from lying down
Poor
Fair
Good
Very Good
Excellent
Select one
21. Tick the box that best describes your dog's overall quality of life over the last 7 days.
Poor
Fair
Good
Very Good
Excellent
Select one
Submit Survey
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