Canine Cognitive Assessment Tool

1

Owner's Name* This field is required.

First Name

Last Name

2

Owner's Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

4

Owner's Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

5

Pet's name* This field is required.

6

Gender* This field is required.

7

Species* This field is required.

8

Breed* This field is required.

9

Age* This field is required.

10

Weight* This field is required.

11

Regular Veterinary Clinic* This field is required.

12

How did you hear about us?* This field is required.

13

Presenting Condition(s)* This field is required.what illness/illnesses does your pet suffer from

14

My dog appears lost or confused in a familiar environment (inside/outside)* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

15

My dog struggles to recognize familiar people and animals inside or outside my home* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

16

My dog responds abnormally to familiar objects around my home* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

17

My dog wanders around without purpose or direction* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

18

My dog has difficulty performing previously learned tasks* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

19

Spatial Awareness* This field is required.your pet's score is:

20

Spatial Awarenessyour pet's score is

21

My dog has abnormal nighttime behaviors (wandering, vocalization, restlessness)* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

22

My dog sleeps most of the day* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

23

B score* This field is required.

24

Sleep-wake cyclesyour pet's score is

25

My dog is less interested in interacting with other people or animals (welcoming, petting, playing, etc.)* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

26

My dog no longer enjoys activities that used to excite them (playing with toys, walks/ exercise, etc.)* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

27

My dog is less responsive to commands* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

28

My dog appears anxious with changes in routine or in new environments* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

29

My dog has acted fearful or aggressive toward people, animals, or environmental stimuli* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

30

C score* This field is required.

31

Social interactionsyour pet's score is

32

My dog eliminates in random locations around the house* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

33

My dog eliminates in their kennel or sleeping area* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

34

My dog has shown a change in how/when they ask to go outside* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

35

My dog sometimes eliminates indoors and/or outdoors after a current walk or trip outside* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

36

My dog eliminates in unusual outdoor locations (rocks, concrete, etc.)* This field is required.

I have never observed this behavior in my pet

I have observed this behavior at least once in the last 6 months

I have observed this behavior at least once per month

I have observed this behavior at least 2-4 times per month

I have observed this behavior several times per week

37

D score* This field is required.

38

House soilingyour pet's score is

39

Final Score* This field is required.

40

Final Score* This field is required.

41

Your Final Score is: {finalScore}

HOW TO SCORE YOUR RESULTS

0-7 Your pet may not be showing signs of cognitive decline
8-23 Your pet may be showing signs of early cognitive decline
24-44 Your pet may be showing signs of moderate cognitive decline
45-95 Your pet may have severe cognitive decline

42

How is my pet's overall health compared to the initial diagnosis/illness* This field is required.

Worse

Same

Better

43

Are you interested in a virtual or an in-home quality of life consultation with one of our doctors?* This field is required.

YESNO

44

Are you interested in scheduling an End of Life Visit for your pet?* This field is required.

YESNO

45

Thank you for your interest in scheduling an appointment. Once you submit this form, you’ll be redirected to our Request an Appointment form to complete your request.