Canine Brief Pain Inventory - Kalinga Park Veterinary Surgery

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Welcome to your Pain Assessment Questionnaire

Select the one number that best describes the pain at its worst in the last 7 days.
0 is none, 10 is extreme

0 1 2 3 4 5 6 7 8 9 10 None

Select the number that best describes the pain at its least in the last 7 days (0 is none , 10 is extreme pain)

0 1 2 3 4 5 6 7 8 9 10 None

Select the number that best describes the pain at its average in the last 7 days.

0 1 2 3 4 5 6 7 8 9 10 None

Select the number that best describes the pain as it is right now

0 1 2 3 4 5 6 7 8 9 10 None

0 = doesnt intefer , 10 = completely interfers

Fill in the oval next to the one number that best describes how during the last 7 days pain has interfered with your dog's:

General Activities

0 1 2 3 4 5 6 7 8 9 10 None

Enjoyment of Life

0 1 2 3 4 5 6 7 8 9 10 None

Ability to Rise to Standing From Lying Down

0 1 2 3 4 5 6 7 8 9 10 None

Ability to Walk

0 1 2 3 4 5 6 7 8 9 10 None

Ability to Run

0 1 2 3 4 5 6 7 8 9 10 None

Ability to Climb Stairs, Curbs, Doorsteps, etc

0 1 2 3 4 5 6 7 8 9 10 None

Select number that best describes your dog's overall quality of life over the last 7 days

0 1 2 3 4 5 6 7 8 9 10 None

Fill in the captcha

Please enter any other notes you might have regarding your Pet's condition

Patient Name

Client Name

Mobile Phone

Time's up

The Canine Brief Pain Inventory (Canine BPI; www.CanineBPI.com ) copyright is held
by Dr. Dorothy Cimino Brown