Helsinki Chronic Pain Index
Owner's name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pet's Name
*
Date
*
/
Month
/
Day
Year
Date
Rate your pet's attitude and/or mood:
*
Very alert
Alert
Neither alert nor disinterested
Disinterested
Very disinterested/lethargic
Rate your pet's willingness to participate in play or interact:
*
Very willing
Willing
Reluctant
Very reluctant
Does not participate or interact at all
Rate your pet's frequency in vocalization or discomfort behaviour (audible whining, grunting, yelping, or unusual licking):
*
Never
Hardly ever
Sometimes
Often
Very often
Rate your pet's eagerness to walk:
*
Very eager
Eager
Reluctant
Very reluctant
Does not want to walk at all
Rate your pet's ability and/or willingness to walk up and/or down stairs:
*
Very willing/able
Willing/able
Reluctant
Very reluctant
Does not do stairs at all
Rate your pet's ability and/or willingness to run:
*
Very willing/able
Willing/able
Reluctant
Very reluctant
Does not run at all
Rate your pet's ability and/or willingness to jump (onto bed, couch, vehicle, etc):
*
Very willing/able
Willing/able
Reluctant
Very reluctant
Does not jump at all
Rate your pet's ease in lying down:
*
Very easy
Easy
Neither easy nor difficult
Difficult
Very Difficult
Rate your pet's rising from a down position:
*
Very easy
Easy
Neither easy nor difficult
Difficult
Very Difficult
Rate your pet's ease of movement after a long rest:
*
Very easy
Easy
Neither easy nor difficult
Difficult
Very Difficult
Rate your pet's ease of movement during and/or after exercise/walks (tired, dragging feet, scuffing nails, lying down):
*
Very easy
Easy
Neither easy nor difficult
Difficult
Very Difficult
Total
0-11 No perceivable pain
12-22 Mild pain
23-28 Moderate pain
29-33 Severe pain
34-44 Debilitating pain
Submit
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