Pet Assessment Form Please complete the form below. 7 Please complete our Pet Assessment Form All fields marked with * are required and must be filled. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Pet's Name *DESCRIPTION OF STIFFNESS The following questions concern the amount of joint stiffness your pet has experienced in the past 7 days. Stiffness is the restriction or slowness in the ease with which your pet moves his/her joints. Please select one answer for each question below. How severe is your pet's stiffness after first waking in the morning?NoneMildModerateSevereExtremeLater in the day, how severe is your pet's stiffness after lying down for at least 15 minutes?NoneMildModerateSevereExtremeHow much of a problem does your pet have rising to standing after lying down for at least 15 minutes?NoneMildModerateSevereExtremeIn general, over the past 7 days, how much difficulty has your pet had with his or her joints?NoneMildModerateSevereExtremeDESCRIPTION OF FUNCTION Please indicate how much of a problem each of the following activities has been for your pet over the past 7 days. Please select one answer for each question below. Jumping up (as in getting into the car or onto the bed)?No problemsMild problemsModerate problemsSevere problemsExtreme problemsJumping down (as in getting out of the car or off of the bed)?No problemsMild problemsModerate problemsSevere problemsExtreme problemsClimbing up (as in stairs, ramps or curbs)?No problemsMild problemsModerate problemsSevere problemsExtreme problemsClimbing down (as in stairs, ramps or curbs)?No problemsMild problemsModerate problemsSevere problemsExtreme problemsDESCRIPTION OF FUNCTION DESCRIPTION OF GAIT The following questions concern your pet’s gait over the past 7 days. Gait refers to the manner in which your dog uses its legs as it moves. Please select one answer for each question below. On average, how severe was your pet's limp during mild activities (such as short walks)?NoneMildModerateSevereExtremeOn average, how severe was your pet's limp during moderate activities (such as long walks, playing or running)?NoneMildModerateSevereExtremeHow often did your pet limp the day after moderate activities (such as long walks, playing or running)?NoneMildModerateSevereExtremeHow often have you been aware of your pet's joint problems?NoneMildModerateSevereExtremeHow often did your dog 'pay' for over-activity, with increased pain or stiffness the following day?NoneMildModerateSevereExtremeDESCRIPTION OF QUALITY OF LIFE Please select one answer for each question below. In the past 7 days, what has been your level of concern that your pet's joint problems will shorten his or her life?NoneMildModerateSevereExtremeIn the past 7 days, what has been your level of concern that your pet is generally slowing down?NoneMildModerateSevereExtremeOverall, how would you rate your pet's quality of life over the past 7 days?ExcellentVery goodGoodFairPoorADDITIONAL QUESTIONS What medications and supplements are your pet currently taking?Are there any other dogs at home?YesNoDo you have stairs in your home?YesNoDoes your pet have any food allergies? (If yes, please explain)What current activities are you doing with your pet?Submit
