Pain Management History Form

Current Problem and Medical History

Your Name:

Your Email:

Pet’s Name:

Date:

In general, how do you rate your pet’s health?
 Excellent Very Good Good Fair Poor

Has your pet ever seen a veterinarian because of joint pain, stiffness or limping?
 Yes No
Please explain:

Living in pain can lead to changes in behavior, which can be hard to read in a pet.
On average, would you say your pet: (choose one)
 Is completely uninterested in its surroundings; sleeps all the time? Will show interest, but no longer comes to greet you? Is mostly interested in life and food, but reluctant to play? Plays only when encouraged, and not for long? Has had no change in personality?

Has your pet’s activity level changed? (check all that apply)
 Seeks more affection than usual Has difficulty getting up from a lying position Lies very still Reluctant to move Shows trembling Becomes restless Repetitively gets up and lies down Shows circling Does not wag tail Trouble posturing for bowel movements
Other

Has your pet’s appetite or thirst changed?
 Yes No

Does your pet have trouble in areas where it never used to need assistance? (check all that apply)
 Cannot manage any steps without assistance Cannot manage a full flight of steps (only 2 to 4 steps alone) Manages a full flight of steps, but has difficulty Can only go upstairs without assistance Has trouble on slippery floors Can only go downstairs without assistance No problems on stairs Cannot jump onto the furniture without assistance Cannot get into the vehicle without assistance Has no trouble jumping

Has your pet become protective of itself? (check all that apply)
 Protects hurt body part Hides Doesn’t put weight on a limb Limps Doesn’t want to be held or picked up Does not like to be brushed/groomed
Other

How long can your pet walk without getting tired, limping, or stopping?
 Less than 5 minutes 10 to 20 minutes More than 30 minutes/my pet doesn’t get tire or sore Does not show signs until finished walking and rests for a while (ie: will stiffen up)

Did your pet’s signs begin slowly or suddenly?
 Slowly, over the course of a few months Suddenly, within days or a few weeks

Has the joint pain suddenly gotten worse?
 Within the past few days Within the past few weeks Not applicable

In the morning, are the affected areas stiff for more than half an hour?
 Yes No There is no morning stiffness

Has your pet had a joint/bone injury or surgery?
 Yes No Unsure
Details:

Which of the following methods do you use to manage your pet’s pain, swelling, or stiffness?
(check all that apply)
 Physical activity/exercise Nutritional supplements Weight management Physical rehabilitation/chiropractic/massage Cold or heat treatment Medication Laser None
Other

Which medication and/or joint supplements do you currently give your pet?
Prescription medication from veterinarian:

Over-the-counter medication:

Aspirin:

Glucosamine human medication (brand):

Veterinary joint supplement (brand):

Herbal supplement (brand):

Other:

Does your pet have any of the following conditions? (check all that apply)
 Kidney disease Skin disease Liver disease Active infection Lung disease Bladder problems Cardiovascular disease
Other:

What are your goals for your pet?