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Pain Forms
Form A – Chronic Pain Behaviour Index
Form B – Pain Questions
Form C – Helsinki Chronic Pain Index
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Form A – Chronic Pain Behaviour Index
Please complete this index prior to your first appointment. We shall then ask you to record behaviour on a weekly basis for the next 3 weeks.
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Name
*
First
Last
Email
*
Pet's Name
*
Pet's Age
*
Breed
*
Date of Survey
*
Current Medications and Dosage
Does your pet look around suddenly or snatch towards tail/back end or into the air?
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Does your pet lick the floor/foreign objects or lick, chew or bite themselves?
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0
Is your pet vocalising more than normal?
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0
Is your pet more touch sensitive e.g. do they resent being groomed or having a harness on?
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0
Is your pet more noise sensitive?
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0
Does your pet have an altered sleeping pattern or position?
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0
Is your pet more anxious and restless/unable to settle?
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Is your pet more nervous? e.g. hides away, shakes/trembles.
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from faeces, toileting
Has your pet had any change in toileting behaviour? e.g. walks forward when passing faeces, urinates more frequently or inappropriately.
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0
Please rate your pet's mood/overall demeanour.
Does your pet have changes in appetite or eating behaviour? e.g. moves away from his/her food bowl or stands/lies to eat.
Any other changes in behaviour and other comments.
Submit
