Osteoarthritis Dog Questionnaire
Owner questionnaire for dogs with mobility problems
Full Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
Pet's name
Pet's Breed
Pet's age
Sex: M/F
Male
Female
For Office Use only: Reference Limb
RF
LF
LH
RH
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Background
1. How long has your pet been suffering with his/her mobility problems?
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?
Yes
No
If yes, please list these if you can:
3. If you can, please list any medications that your pet is currently receiving, stating when he/she received the last dose of each:
Yes
No
Not Sure
4. If you can, please list any medications that your pet is currently receiving, stating when he/she received the last dose of each:
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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 pf exercise is this?
Always on leash
Mostly on leash
Mostly off leash
Always of leash
Working
4. Are there particular days of the week upon which your dog has significantly more exercise? (Check more boxes if necessary)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
5. On what sort sort of terrain does your dog most often excercise?
On level grass
In woodland
On street
Over Rough ground
6. At exercise, how is your dog handled?
Walk on leash
Walk off leash
On street
Over rough ground
7. Who limits the extent to which your dog exercises?
You
Your dog
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Mobility
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
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
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 excercise?
Very good
Good
Fair
Poor
Very poor
9. What overall effect does exercise have on your dogs 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
Total Score
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