Cognitive Dysfunction Screening Checklist Date Date Format: MM slash DD slash YYYY Owners NameSpeciesCanineFelinePet's NameAgeSexMaleFemaleNeuteredYesNoCognitive 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 / walls1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severeRelationships – 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: Agression1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severeAggression to family members to family pets to unfamiliar people unfamiliar pets otherResponse 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 / odor1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severeActivity / 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 / agitation1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe6: Age first noticed6: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severeActivity – apathy / depressed 1. Decreased interest in food / treats 2. Decreased exploration / activity 3: Decreased interest in social interactions / play 4: Decreased self-care1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severeSleep – wake cycles; reversed day/night schedule 1. Restless sleep/waking at nights 2. Increased daytime sleep1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severeLearning 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: Incontinence1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe5: Age first noticed5: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severeLearning 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 / pets1: Age first noticed1: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe2: Age first noticed2: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe3: Age first noticed3: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe4: Age first noticed4: ScoreScoring Key: 0 – none; 1 – mild; 2 – moderate; 3 – severe
