Brief Pain Inventory Form & New Patient Questionaire "*" indicates required fields Name* First Last Phone*Email* Pet's name* Describe pet's painRate your pet's painNumeric Scale from 0= no pain to 10= extreme pain012345678910Description of functionUsing 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 lifestyleGeneral activity012345678910Enjoyment of life012345678910Ability to rise to standing from lying down012345678910Ability to walk012345678910Ability to climb stairs, curbs, doorsteps, etc.012345678910Overall impression*Select the choice that best describes your pet’s overall quality of life over the last seven days. Poor Fair Good Very Good Excellent Current medications/supplementsTo 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.Glucosamine / Chondroitin Glucosamine / Chondroitin Glucosamine / Chondroitin brand Glucosamine / Chondroitin amount given Fish Oil Fish Oil Fish oIl brand Fish oil amount given SAMe SAMe SAMe brand SAMe amount given Carprofen Carprofen Carprofen mg size Carprofen amount given Meloxicam Meloxicam Meloxicam mL size Meloxicam amount given Galliprant Galliprant Galliprant mg/mL size Galliprant amount given Gabapentin Gabapentin Gabapentin mg/mL size Gabapentin amount given Amantadine Amantadine Amantadine mg/mL size Amantadine amount given Adequan Adequan Adequan mg size Adequan frequency given CBD Oil CBD Oil CBD oil mL administered CBD oil frequency given Other Other Other mg/mL size Other amount given DietPlease let us know the brand, variety, and amount of pet food your pet eats daily. Pease also include any treats your pet eats.NameThis field is for validation purposes and should be left unchanged.