Canine Cognitive Dysfunction Checklist Form
Use this Canine Cognitive Dysfunction Checklist Form to record observed signs and their severity in your dog.
Dog's Name
Dog's Age (years)
Disorientation (e.g., gets lost in familiar places)
Not at all
1
2
3
4
Very frequently
5
1 is Not at all, 5 is Very frequently
Altered interactions with people or pets (e.g., less social, more withdrawn)
No change
1
2
3
4
Major change
5
1 is No change, 5 is Major change
Sleep-wake cycle changes (e.g., restlessness at night, sleeping more during day)
No change
1
2
3
4
Major change
5
1 is No change, 5 is Major change
House soiling accidents (loss of previously learned house training)
Never
1
2
3
4
Very frequent
5
1 is Never, 5 is Very frequent
Activity level changes (e.g., pacing, restlessness, decreased activity)
No change
1
2
3
4
Major change
5
1 is No change, 5 is Major change
Anxiety or agitation (e.g., increased vocalization, panting, clinginess)
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Select any additional signs observed
Repetitive behaviors (e.g., circling, staring)
Difficulty finding food or water
Getting stuck in corners or behind objects
Other (please specify)
Comments or additional observations
Submit Checklist
Should be Empty: