Canine Rehabilitation Pain Inventory

Canine Rehabilitation Pain Inventory
Date*

MonthDayYear
Date
Client Name*

First NameLast Name
Pet Name*
Description of Pain

Please rate your dog's pain
What best describes your dog's pain at its WORST in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Extreme Pain
What best describes your dog's pain at its LEAST in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Extreme Pain
What best describes your dog's pain on AVERAGE in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Extreme Pain
What best describes your dog's pain right now?*

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Extreme Pain
Description of Function
How has pain interfered with your dog's general activity in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's enjoyment of life in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to rise to standing from lying down in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to walk in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to run in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to climb stairs, curbs, doorsteps, etc in the last 7 days?*

0

1

2

3

4

5

6

7

8

9

10

0 is Does Not Interfere, 10 is Completely Interferes
Overall Impression
What best describes your dog's overall quality of life over the last 7 days?*
Should be Empty:

Canine Rehabilitation Pain Inventory

Description of Pain

Description of Function

Overall Impression