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? ExcellentVery GoodGoodFairPoor Has your pet ever seen a veterinarian because of joint pain, stiffness or limping? YesNo 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 usualHas difficulty getting up from a lying positionLies very stillReluctant to moveShows tremblingBecomes restlessRepetitively gets up and lies downShows circlingDoes not wag tailTrouble posturing for bowel movements Other Has your pet’s appetite or thirst changed? YesNo Does your pet have trouble in areas where it never used to need assistance? (check all that apply) Cannot manage any steps without assistanceCannot manage a full flight of steps (only 2 to 4 steps alone)Manages a full flight of steps, but has difficultyCan only go upstairs without assistanceHas trouble on slippery floorsCan only go downstairs without assistanceNo problems on stairsCannot jump onto the furniture without assistanceCannot get into the vehicle without assistanceHas no trouble jumping Has your pet become protective of itself? (check all that apply) Protects hurt body partHidesDoesn’t put weight on a limbLimpsDoesn’t want to be held or picked upDoes not like to be brushed/groomed Other How long can your pet walk without getting tired, limping, or stopping? Less than 5 minutes10 to 20 minutesMore than 30 minutes/my pet doesn’t get tire or soreDoes 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 monthsSuddenly, within days or a few weeks Has the joint pain suddenly gotten worse? Within the past few daysWithin the past few weeksNot applicable In the morning, are the affected areas stiff for more than half an hour? YesNoThere is no morning stiffness Has your pet had a joint/bone injury or surgery? YesNoUnsure Details: Which of the following methods do you use to manage your pet’s pain, swelling, or stiffness? (check all that apply) Physical activity/exerciseNutritional supplementsWeight managementPhysical rehabilitation/chiropractic/massageCold or heat treatmentMedicationLaserNone 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 diseaseSkin diseaseLiver diseaseActive infectionLung diseaseBladder problemsCardiovascular disease Other: What are your goals for your pet?