02 9086 9130
hello@rousehillfamilyvets.com.au
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Pain Scale Questionnaire

APPOINTMENT

Please fill out this form as completely and accurately as possible before your pet’s procedure. If you have questions, don’t hesitate to give us a call at 02-9086-9130.

Email *

Pet's Name: *

Your full name: *

First

Last

PAIN

Please provide us with a description of how you perceive your dogs pain and rate their pain below.

Please describe your dogs pain *

Choose the number that best describes the pain at its WORST in the last 7 days *

No Pain
1
2
3
4
5
6
7
8
9
10
Extreme Pain

Choose the number that best describes the pain at its LEAST in the last 7 days *

No Pain
1
2
3
4
5
6
7
8
9
10
Extreme Pain

Choose the number that best describes the pain at its AVERAGE in the last 7 days *

No Pain
1
2
3
4
5
6
7
8
9
10
Extreme Pain

Choose the number that best describes the pain as it is RIGHT NOW *

No Pain
1
2
3
4
5
6
7
8
9
10
Extreme Pain

FUNCTION

Choose the number that best describes how during the last 7 days PAIN HAS INTERFERED with your pets:

General activity *

Does not interfere
1
2
3
4
5
6
7
8
9
10
Completely interferes

Enjoyment of Life *

Does not interfere
1
2
3
4
5
6
7
8
9
10
Completely interferes

Ability to Rise to Standing from Lying Down *

Does not interfere
1
2
3
4
5
6
7
8
9
10
Completely interferes

Ability to Walk *

Does not interfere
1
2
3
4
5
6
7
8
9
10
Completely interferes

Ability to Run *

Does not interfere
1
2
3
4
5
6
7
8
9
10
Completely interferes

Ability to Climb Stairs, Curbs, Doorsteps etc. *

Does not interfere
1
2
3
4
5
6
7
8
9
10
Completely interferes

OVERALL IMPRESSION

Choose the option which best describes your pet's overall quality of life over the last 7 days *

Poor
Fair
Good
Very Good
Excellent

Any other additional comments or concerns about quality of life?

Making a difference when it matters the most

Address

10/591 Withers Road,
Rouse Hill NSW 2155

Click here for directions.

Opening Hours

Monday - Thursday: 9am - 6pm
Friday: 9am - 5pm
Saturday: 9am - 1pm
Sunday & Public Holidays Closed

In-home euthanasia services run outside of opening hours by appointment only

Contact

Phone: 02 9086 9130
Email: hello@rousehillfamilyvets.com.au

Have a question?

Please fill out the form below and a member of our team will be in touch with you shortly. Alternatively please contact us directly at 02 9086 9130.

Name *

First

Last

Email *

Phone

How can we help you? *

Comment

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