*Client Name: *Patient Name: *Phone Number: *Email:
1. Since starting the monthly injections, how would you describe your dog's overall comfort? Much worseWorseNo changeImprovedGreatly improved
2. How often does your dog show signs of pain (e.g., limping, whimpering, stiffness, slow to rise, etc)? DailyA few times per weekOccasionallyRarelyNot at all
3. When does your dog seem most uncomfortable? (Check all that apply) After waking upAfter exerciseDuring cold or damp weatherAt nightNo specific time
4. Have you noticed any changes in your dog's behavior?
Activity level: DecreasedNo ChangeImproved
Willingness to play: DecreasedNo ChangeImproved
Ability to go on walks: DecreasedNo ChangeImproved
Jumping/climbing (e.g. stairs, couch): DecreasedNo ChangeImproved
Appetite: DecreasedNo ChangeImproved
Mood or demeanor: DecreasedNo ChangeImproved
PAIN SIGNS CHECKLIST Please check any of the following signs that have been observed in the past month: Limping or lamenessDifficulty standing up or lying downReluctance to jump or climbWhining or yelpingLicking/chewing at jointsAvoiding being touched or handledHiding or isolatingAggression or irritabilityRestlessness or pacingChange in posture or gaitShaking or trembling
SIDE EFFECTS OR CONCERNS Have you noticed any of the following since the injections began?
Vomiting: YesNo
Diarrhea: YesNo
Increased drinking/urination: YesNo
Lethargy: YesNo
Swelling or redness at injection site: YesNo
Skin irritation or hair loss: YesNo
Other concerns or symptoms noticed:
OWNER SATISFACTION
1. How satisfied are you with the pain management treatment so far? DissatisfiedNeutralSatisfied
2. Would you like to continue the injections? YesNoNot sure
3. Would you like to have a consultation with a doctor before continuing with the ketamine pain injections? NoYes
How would you like to consult with the doctor? Schedule consult appt in personSchedule telephone consultation
4. Are there any additional comments or concerns at this time? NoYes
If yes, please describe:
