314-951-1534

Brief Pain Inventory and New Patient Questionnaire

Numeric Scale from 0= no pain to 10= extreme pain

Description of function

Using a Numeric Scale, rate how pain has interfered with your pet’s lifestyle during the last seven days. 0= no interference on your pet’s lifestyle to 10= Completely interferes with your pet’s lifestyle

Select the choice that best describes your pet’s overall quality of life over the last seven days.

Current Medications/Supplements

To help us better understand what products your pet is receiving, please check the box and tell us the type and amount of each product that your pet is taking.

Please let us know the brand, variety, and amount of pet food your pet eats daily. Pease also include any treats your pet eats.