Non Surgical Owner Assessment - Gulf Coast Veterinary Specialists

Pet's Name*

Nickname(s)*

Please list current medications and any other medical conditions/Injuries (include dates if condition or injury was in the past).

If condition is due to an accident, when did your pet’s injury occur?

When did it occur?

If non-traumatic in origin, how long has your pet had symptoms?

Has your pet been getting better or worse?

Better
Worse

What aggravates the problem?

What eases the problem?

Have there been any new playing or working activities introduced to your pet?

Is the problem/pain affected by time of day or activity?

Yes
No

What specific functional problems is your pet having? (Example: rising from lying down on tile floors)

What other treatments has your pet received for this problem? When?

Please describe.

What commands does your pet follow (i.e. Sit? Heel?)? What is the word you use for “treats”?

May your pet receive Science Diet treats during the therapy session? (If not, please bring appropriate treats for your pet.)

Yes
No

What is your pet’s favorite motivator? (Ball? Treats? Petting?)

How many caregivers for your pet are in the home?

What specific goals do you have for your pet’s recovery? (Examples: (1) Climb 4 stairs into home without assistance, (2) Resume jogging 3 miles with me, (3) Regain strength to play with children, (4) Return to hunting.)

Your Pet's Activity Levels

Please select one number on each of the five scales to indicate your pet’s current activity levels.

Stairs*

(10) - No difficulty
(6) - Slight difficulty
(2) - Skips steps or bunny hops
(0) - Unable to perform

Sits*

(10) - Sits and rises squarely with no difficulty
(6) - Sits and rises with slight difficulty
(2) - Sits and rises with difficulty
(0) - Unable to sit or rise independently

Stand*

(10) - Can stand for periods longer than 1 minute
(8) - Can stand between 30 and 60 seconds before sitting
(6) - Can stand between 10 and 30 seconds before sitting
(4) - Can stand between 1 and 10 seconds before sitting
(2) - Prefers to always sit
(0) - Cannot stand

Pain*

(10) - None – performs all activities without pain
(8) - Mild pain upon rising
(6) - Mild pain throughout the day
(4) - Moderate pain that improves with activity
(2) - Moderate pain throughout the day
(0) - Severe pain throughout the day

Owner's Perception of Pet's Quality of Life*

(10) - Great quality of life without limitations
(8) - Great quality of life with limitations
(6) - Good quality of life without limitations
(4) - Good quality of life with limitations
(2) - Fair quality of life
(0) - Poor quality of life

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