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Pet Acupuncture NI

Initial Visit

Owner questionnaire for dogs with mobility problems

Dear Owner,

Thank you for agreeing to complete this questionnaire.

Your assistance in this endeavour will enable us to gather valuable information about your pet, and is a vital component in our ongoing quest to combat painful and debilitating diseases such as arthritis. It is important that all questions are answered to the best of your ability and if you have a question regarding the questionnaire, please contact a health care member from your veterinary clinic.

Thank you again for your help.

Answering the questions

Most of the questions are fairly simple. It is important that you only check one box per question except where otherwise requested (e.g. Question 4 under Lifestyle).


If you are in any doubt as to how to answer a particular question, please contact a member of staff for assistance.

Sex
M
F

For office use only

Reference limb

Background

1. How long has your pet been suffering with his/her mobility problem?
Up to 6 months
6–12 months
12–24 months
24–36 months
more than 36 months
2. Has your dog been diagnosed as suffering from any other problems in addition to his/ her orthopedic disease?
No
Yes

Lifestyle

1. In the last week, on average, how far has your dog exercised each day?
0–0.6 miles
0.6–1.2 miles
1.2–1.9 miles
1.9–2.5 miles
more than 2.5 miles
2. In the last week, on average, how many walks has your dog had each day?
0
1
2
3
4
more than 4
3. What type of exercise is this?
Always on leash
Mostly on leash
Mostly off leash
Always off leash
Working
4. Are there particular days of the week upon which your dog has significantly more exercise? (Check more than one box if necessary.)
5. On what sort of terrain does your dog most often exercise?
On level grass
In woodland
On street
Over rough ground
6. At exercise, how is your dog handled?
Walk on leash
Walk off leash
Trot
Run freely
7. Who limits the extent to which your dog exercises?
You
Your dog

Mobility

Generally

1. How is your dog’s mobility in general?
Very good
Good
Fair
Poor
Very poor
2. How disabled is your dog by his/her lameness?
Not at all disabled
Slightly disabled
Moderately disabled
Severely disabled
Extremely disabled
3. How active is your dog?
Extremely active
Very active
Moderately active
Slightly active
Not at all active
4. What is the effect of cold, damp weather on your dog’s lameness?
No effect
Mild effect
Moderate effect
Severe effect
Extreme effect
5. To what degree does your dog show stiffness in the affected leg after a ‘lie down’?
No stiffness
Mild stiffness
Moderate stiffness
Severe stiffness
Extreme stiffness

At exercise

6. At exercise, how active is your dog?
Extremely active
Very active
Fairly active
Not very active
Not at all active
7. How interested is your dog in exercising?
Extremely interested
Very interested
Fairly interested
Not very interested
Not at all interested
8. How would you rate your dog’s ability to exercise?
Very good
Good
Fair
Poor
Very poor
9. What overall effect does exercise have on your dog’s lameness?
No effect
Mild effect
Moderate effect
Severe effect
Extreme effect
10. How often does your dog rest (stop/sit down) during exercise?
Never
Hardly ever
Occasionally
Frequently
Very frequently
11. What is the effect of cold, damp weather on your pet’s ability to exercise?
No effect
Mild effect
Moderate effect
Severe effect
Extreme effect
12.To what degree does your dog show stiffness in the affected leg after a ‘lie down’ following exercise?
No stiffness
Mild stiffness
Moderate stiffness
Severe stiffness
Extreme stiffness
13. What is the effect of your dog’s lameness on his/her ability to exercise?
No effect
Mild effect
Moderate effect
Severe effect
Extreme effect

Thank you once again for completing this questionnaire.

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