Osteoarthritis Pain Evaluation
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Current EAMC Client
New EAMC Client
Client's Name
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First Name
Last Name
Pet's Name
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Phone Number
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Area Code
Phone Number
Pet's Current Medications
Osteoarthritis Pain
Arthritis pain can be a serious heath problem for your pet. Pets can be good at hiding almost everything, especially pain. You know your pet's playful ways and what they enjoy better than anyone. Changes in these behaviors can be signs of osteoarthritis pain.
1. Fill in the oval next to the one number that best describes the pain at its WORST in the last 7 days.
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No pain
Extreme Pain
1 is No pain, 10 is Extreme Pain
2. Fill in the oval next to the one number that best describes the pain at its LEAST in the last 7 days.
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10
No pain
Extreme Pain
1 is No pain, 10 is Extreme Pain
3. Fill in the oval next to the one number that best describes the pain at its AVERAGE in the last 7 days.
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No pain
Extreme Pain
1 is No pain, 10 is Extreme Pain
4. Fill in the oval next to the one number that best describes the pain at it is RIGHT NOW.
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No pain
Extreme Pain
1 is No pain, 10 is Extreme Pain
Description of function:
Fill in the oval next to the one number that best describes how during the last 7 days PAIN HAS INTERFERED with your pets
5. General Activity
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Does not interfere
Completely Interferes
1 is Does not interfere, 10 is Completely Interferes
6. Enjoyment of life
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Does not interfere
Completely Interferes
1 is Does not interfere, 10 is Completely Interferes
7. Ability to rise to standing from lying down
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Does not interfere
Completely Interferes
1 is Does not interfere, 10 is Completely Interferes
8. Ability to Walk
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Does not interfere
Completely Interferes
1 is Does not interfere, 10 is Completely Interferes
9. Ability to run
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Does not interfere
Completely Interferes
1 is Does not interfere, 10 is Completely Interferes
10. Ability to climb stairs, curbs, doorsteps, etc.
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Does not interfere
Completely Interferes
1 is Does not interfere, 10 is Completely Interferes
Overall Impression
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
Any additional information you would like to add in regards to your pet's mobility?
Total Score
Date of Consultation Requested
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Date
2nd Choice Date of Consultation Requested
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Month
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Date
Type of Consultation
Please Select
Phone Consultation
In-Person Consultation
*Patient must have been seen within the last 6 months to have phone consultation
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