COGNITIVE DYSFUNCTION SYNDROME EVALUATION TOOL

COGNITIVE DYSFUNCTION SYNDROME ASSESSMENT TOOL
Date*

MonthDayYear
Date
Owners name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Pets name*
Breed*
Age*
Gender*
Weight*
in lbs
Body Condition Score*
Current Diet*
Brand and Amount Feeding
Medications and Dosage Frequency*
Name/Dose in mg/Frequency
Please complete this canine senior pet cognitive assessment. If you've noticed changes in multiple behavioral categories, be sure to talk to your veterinarian today about the health of your pet's aging brain.
BEHAVIORAL SIGNS

Identify signs that have arisen or progressed since 8 years of age and older. (Score as O=none, 1=mild, 2=moderate, 3=severe)
DISORIENTATION
Gets stuck, difficulty getting around objects, goes to hinge side of door*

0

1

2

3

0 is none, 3 is severe
Total
Stares blankly at walls, floor, or into space*

0

1

2

3

0 is none, 3 is severe
Total
Does not recognize familiar people/familiar pets*

0

1

2

3

0 is none, 3 is severe
Total
Gets lost in home or yard*

0

1

2

3

0 is none, 3 is severe
Total
Less reactive to visual (sights) or auditory (sounds) stimuli*

0

1

2

3

0 is none, 3 is severe
Total
SOCIAL INTERACTIONS
More irritable/fearful/aggressive with visitors, family or other animals*

0

1

2

3

0 is none, 3 is severe
Total
Decreased interest in approaching, greeting or affection/petting*

0

1

2

3

0 is none, 3 is severe
Total
SLEEP/WAKE CYCLES
Pacing/restless/sleeps less/waking at night*

0

1

2

3

0 is none, 3 is severe
Total
Vocalization at night*

0

1

2

3

0 is none, 3 is severe
Total
HOUSESOILING, LEARNING AND MEMORY
Less able to learn new tasks or respond to previously learned commands/name/work*

0

1

2

3

0 is none, 3 is severe
Total
Indoor soiling of urine or stool/decreased signaling to go out*

0

1

2

3

0 is none, 3 is severe
Total
Difficulty getting dogs attention/increased distraction/decreased focus*

0

1

2

3

0 is none, 3 is severe
Total
ACTIVITY
Decrease in exploration or play with toys, family members, other pets*

0

1

2

3

0 is none, 3 is severe
Total
Increased activity including aimless pacing or wandering*

0

1

2

3

0 is none, 3 is severe
Total
Repetitive behaviors, e.g. circling/chewing/licking or stargazing*

0

1

2

3

0 is none, 3 is severe
Total
ANXIETY
Increased anxiety when separated from owners*

0

1

2

3

0 is none, 3 is severe
Total
More reactive/fearful to visual (sights) and auditory (sounds) stimuli*

0

1

2

3

0 is none, 3 is severe
Total
Increased fear of places/locations, e.g. new environments/going outdoors*

0

1

2

3

0 is none, 3 is severe
Total
Total
SCORE:

0-4 No Cognitive Dysfunction
4-15 Mild
16-33 Moderate
>33 Severe

Once this form is completed, your veterinarian will determine the cause of these signs through a physical examination and recommended diagnostic tests. However, even if your senior pet is experiencing multiple health issues associated with aging, there may be some degree of CDS.
Assessment was created by: Dr. Gary Landsberg, DVM, DACVB, DECAWBM, Vice President, Veterinary Affairs CanCog Technologies; to aid in diagnosing Canine Cognitive Dysfunction Syndrome. Purina trademarks are owned by Société des Produits Nestlé S.A. Printed in USA. VET0938A-0517

Modified to Jotform format by Kristine Haroldson, DVM, CRPM, FFCP
Should be Empty:

COGNITIVE DYSFUNCTION SYNDROME ASSESSMENT TOOL

BEHAVIORAL SIGNS

DISORIENTATION

SOCIAL INTERACTIONS

SLEEP/WAKE CYCLES

HOUSESOILING, LEARNING AND MEMORY

ACTIVITY

ANXIETY