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Acc Canine Brief Pain Inventory -Form Fill
Q1
First Name
Pet's Name
Q2
Last Name
Pet's Name
Q3
Fill in the oval next to the one number that best describes the pain at its WORST in the last 7 days.
1 is No pain, 10 is Extreme Pain
1
2
3
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9
10
No pain
Extreme Pain
Q4
Fill in the oval next to the one number that best describes the pain at its LEAST in the last 7 days.
1 is No pain, 10 is Extreme Pain
1
2
3
4
5
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9
10
No pain
Extreme Pain
Q5
Fill in the oval next to the one number that best describes the pain at its AVERAGE in the last 7 days.
1 is No pain, 10 is Extreme Pain
1
2
3
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9
10
No pain
Extreme Pain
Q6
Fill in the oval next to the one number that best describes the pain at it is RIGHT NOW.
1 is No pain, 10 is Extreme Pain
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2
3
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9
10
No pain
Extreme Pain
Q7
General Activity
1 is No pain, 10 is Extreme Pain
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10
No pain
Extreme Pain
Q8
Enjoyment of life
1 is No pain, 10 is Extreme Pain
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10
No pain
Extreme Pain
Q9
Ability to rise to standing from lying down
1 is No pain, 10 is Extreme Pain
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10
No pain
Extreme Pain
Q10
Ability to Walk
1 is No pain, 10 is Extreme Pain
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10
No pain
Extreme Pain
Q11
Ability to run
1 is No pain, 10 is Extreme Pain
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10
No pain
Extreme Pain
Q12
Ability to climb stairs, curbs, doorsteps, etc.
1 is No pain, 10 is Extreme Pain
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2
3
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9
10
No pain
Extreme Pain
Q13
Fill in the oval next to the one number that best describes your dog's overall quality of life over the last 7 days.
Q14
Total Score
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