Cognitive Dysfunction Screening Checklist

Date
MM slash DD slash YYYY
Owners Name
Species
- Canine
- Feline
Pet's Name
Age
Sex
- Male
- Female
Neutered
- Yes
- No
Cognitive dysfunction screening checklist
Confusion – 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
3: Age first noticed
3: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
4: Age first noticed
4: Score
Scoring 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
3: Age first noticed
3: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
4: Age first noticed
4: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
5: Age first noticed
5: Score
Scoring 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
3: Age first noticed
3: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
4: Age first noticed
4: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
5: Age first noticed
5: Score
Scoring 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
3: Age first noticed
3: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
4: Age first noticed
4: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
5: Age first noticed
5: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
6: Age first noticed
6: Score
Scoring 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
3: Age first noticed
3: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
4: Age first noticed
4: Score
Scoring 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
3: Age first noticed
3: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
4: Age first noticed
4: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
5: Age first noticed
5: Score
Scoring 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 noticed
1: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
2: Age first noticed
2: Score
Scoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
3: Age first noticed

Cognitive dysfunction screening checklist