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Vet Referral Form
Pain Forms
Form A – Chronic Pain Behaviour Index
Form B – Pain Questions
Form C – Helsinki Chronic Pain Index
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Form C – Helsinki Chronic Pain Index
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Name
*
First
Last
Email
*
Pet's Name
*
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
your a
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
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