Rehabilitation Recheck Form

4176 Meridian Street

Bellingham, WA 98226

(360) 758-2200

24/7 Emergency Care

Medical History: Rehabilitation (Bellingham)

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-982-0166 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Canine Brief Pain Inventory
Contact Information
Your name*
Your email*
We will send you a copy of this form to you.
Your pet's name*
Description of Pain

Rate your dog's pain
Select the one number that best describes the pain at its WORST in the last 7 days:*

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0 is No pain, 10 is Extreme pain
Select the one number that best describes the pain at its LEAST in the last 7 days:*

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0 is No pain, 10 is Extreme pain
Select the one number that best describes the pain at its AVERAGE in the last 7 days:*

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0 is No pain, 10 is Extreme pain
Select the one number that best describes the pain as it is RIGHT NOW:*

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0 is No pain, 10 is Extreme pain
Description of Function

Select the one number that best describes how during the last 7 days pain has interfered with your dog's...
Total
General Activity*

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0 is Does not interfere, 10 is Completely interferes
Enjoyment of Life*

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0 is Does not interfere, 10 is Completely interferes
Ability to Rise to Standing From Lying Down*

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0 is Does not interfere, 10 is Completely interferes
Ability to Walk*

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0 is Does not interfere, 10 is Completely interferes
Ability to Run*

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0 is Does not interfere, 10 is Completely interferes
Ability to Climb Stairs, Curbs, Doorsteps, etc.*

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0 is Does not interfere, 10 is Completely interferes
Overall Impression

Select the one description that best describes your dog's overall quality of life over the last 7 days.*

	Poor	Fair	Good	Very Good	Excellent
Quality of Life

OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us for rehabilitation treatment for your beloved pet:
e.g. I searched Google; My vet recommends you for rehab, etc
Feedback on this form? Send your thoughts to marketing@bbvsh.com
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4176 Meridian Street

(360) 758-2200

Medical History: Rehabilitation (Bellingham)

Canine Brief Pain Inventory

Contact Information

Description of Pain

Description of Function

Overall Impression