Dog Home Pain Assessment Form Dog Pain Assessment Form To learn if your dog could be hiding chronic or acute pain, please check all boxes that apply (even if they only occasionally occur). Once submitted, this form will be reviewed and you will be contacted with the next steps in getting your friend more comfortable! Name * Name First First Last Last Email * Date * Dog's Name * Dog's Age * Grooming/Hair Coat Swollen, red, or inflamed tissue on feet, legs or body Patches of hair loss Licking paws or elsewhere on the body Biting self or pulling hair out Resents being touched or brushed in certain parts of the body Activity General activity seems decreased Slowing down with age Decreased interest in or less time spent playing Changes in interaction with humans or other pets Spends most of their time in one place in the house Spends a large amount of time sleeping in a room away from family Chooses a cold hard floor to sleep on No longer sleeps in human bed Sudden episodes of growling with no apparent reason Sudden episodes of looking at part of body and then licking, pulling hair or biting the area Growls or snaps when someone touches them Seems more irritable than in the past Cries out when moving or when touched Movement Movement seems stiff Suddenly sitting down when walking, playing, or using stairs Runs or uses stairs with feet bounding together Navigates stairs slowly Asks to be picked up instead of jumping on your lap Hesitates or takes several tries before jumping on a surface Bunny hop using either both hind or both front legs together to go up or down stairs Limping (any amount or severity) Bodily Functions Changes in food and water intake Picky about food types Bathroom accidents or “leaking” Has bowel movements less than once daily Has hard, small, or dry bowel movements Vomits more than once monthly If you see a movement or change in your dog’s behavior that you are unsure about, please upload up to 3 videos here. Drop a file here or click to upload Choose File Maximum file size: 52.43MB reCAPTCHA Submit If you are human, leave this field blank.
