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Senior Pet Cognitive Assessment

If your pet is showing signs of aging and you are unsure what you can do to improve his/her quality of life, this online assessment will provide some insight and allow us to help guide you with suggestions tailored to your pet’s specific needs.

This checklist will identify behaviour changes signaling any deterioration in alertness and health. Revealing potential problems early can greatly rejuvenate your pet both mentally and physically, often with simple changes in environment or medication.

Pro Tip: If your pet is due for an annual examination it is helpful to submit this information prior to your visit!

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Client Details

Name

Patient Details

Date of Appointment (if scheduled)

Behavioural Signs

Please identify signs that have arisen / progressed since 8 years of age (and older) to help evaluate your pet's mental acuity.

 

Disorientation- SCORE: 0-none, 1-mild, 2-moderate, 3-severe
0123
Gets stuck, difficulty getting around objects, goes to hinge side of door
0
1
2
3
Stares blankly at walls, floor or into space
0
1
2
3
Does not recognize familiar people / familiar pets
0
1
2
3
Gets lost in home or yard
0
1
2
3
LESS reactive to visual (sights) or auditory (sounds) stimuli
0
1
2
3
Social Interactions- SCORE: 0-none, 1-mild, 2-moderate, 3-severe
0123
More irritable / fearful / aggressive with visitors, family or other animals
0
1
2
3
Decreased interest in approaching, greeting or affection / petting
0
1
2
3
Sleep/Wake Cycles - SCORE: 0-none, 1-mild, 2-moderate, 3-severe
0123
Pacing / restless / sleeps less / waking at night
0
1
2
3
Vocalization at night
0
1
2
3
Housesoiling, Learning - SCORE: 0-none, 1-mild, 2-moderate, 3-severe
0123
Less able to learn new tasks or repond to previously learned commands / name / tasks
0
1
2
3
Indoor soiling of urine / stool, decreased signaling to go out
0
1
2
3
Difficulty getting pet's attention / increased distraction / decreased focus
0
1
2
3
Activity - SCORE: 0-none, 1-mild, 2-moderate, 3-severe
0123
Decrease in exploration or play with toys, family members, other pets
0
1
2
3
Increased activity including aimless pacing or wandering
0
1
2
3
Repetitive behaviours, e.g., circling, chewing, licking, star gazing
0
1
2
3
Anxiety - SCORE: 0-none, 1-mild, 2-moderate, 3-severe
0123
Increased anxiety when separated from owners
0
1
2
3
MORE reactive / fearful to visual (sights) or auditory (sounds) stimuli
0
1
2
3
Increased fear of places / locations (new environments / going outdoors etc.)
0
1
2
3

Place Your Total Score in the Box Below

A score of 4 - 15 is consistent with mild, 16 - 33 is moderate, and 33 or more is considered severe cognitive dysfunction syndrome.

Once this form is completed your veterinarian will discuss with you the cause of these signs and recommend appropriate treatment or diagnostic testing. Please allow a few days for our veterinarians to compile the necessary information and contact you.

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