Name
*
First Name
Last Name
Pet's name
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email*
*
Please select the one that best describes your cat’s ability to perform the following activities.
*
Rows
Normal
Not quite normal
Somewhat worse than normal
Barely, or with great effort
Not at all
Walk and/or move easily?
Run?
Jump up (how well and how easily)?
Jump up to kitchen counter height in one try?
Jump down (how well and how easily)?
Climb up stairs or steps?
Go down stairs or steps?
Play with toys and/or chase objects?
Play and interact with other pets?
Get up from a resting position?
Lie and/or sit down?
Stretch?
Groom himself or herself?
Interact with you and family members?
Tolerate being touched and/or held?
Eat?
Use the litter box (get in and out, squat, cover waste?
Please mark from 1-10 the number that best describes your cat's pain...
*
Rows
1
2
3
4
5
6
7
8
9
10
Over the last 2 weeks
Today
Total
0-20 No pain
21-40 Mild pain
41-60 Moderate pain
61-80 Severe pain
>80 Debilitating pain
Submit
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