Cognitive Dysfunction Screening Checklist Date MM slash DD slash YYYY Owners NameSpecies Canine Feline Pet's NameAgeSex Male Female Neutered Yes No Cognitive dysfunction screening checklistConfusion – awareness – spatial orientation 1. Gets stuck or can’t get around objects 2. Stares blankly at walls or floor 3: Can’t find / leaves dropped food 4: Goes into wrong side of door; walks into door / walls 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe Relationships – social interactions 1. Decreased interest in petting / avoids contact 2. Decreased greeting behavior 3: In need of constant contact, overdependent, “ clingy ” 4: Altered relationship with other household pets – less social 5: Agression 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe Aggression to family members to family pets to unfamiliar people unfamiliar pets other Response to stimuli 1. Decreased response to auditory stimuli (sounds) 2. Increased response, fear, phobia to auditory stimuli 3: Decreased response to visual stimuli (sights) 4: Increased response, fear, phobia to visual stimuli 5: Decreased responsiveness to food / odor 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe Activity / anxiety – increased/repetitive 1. Pacing / wanders aimlessly 2. Snaps at air / licks air 3: Licking owners/ household objects 4: Vocalization 5: Increased appetite (eats quicker or more food) 6: Restless / agitation 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 6: Age first noticed6: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe Activity – apathy / depressed 1. Decreased interest in food / treats 2. Decreased exploration / activity 3: Decreased interest in social interactions / play 4: Decreased self-care 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe Sleep – wake cycles; reversed day/night schedule 1. Restless sleep/waking at nights 2. Increased daytime sleep 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe Learning and memory – housesoiling 1. Indoor elimination at sites previously trained 2. Decrease/loss of signaling 3: Goes outdoors, then returns indoors and eliminates 4: Elimination in crate or sleeping area 5: Incontinence 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe Learning and memory – work, tasks, commands 1. Impaired working ability/decreased ability to perform learned tasks 2. Decreased responsiveness to commands and tricks 3: Inability/slow to learn new tasks (retrain) 4: Decreased recognition of familiar people / pets 1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe 4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe CAPTCHA Δ
