Canine Cognitive Assessment Form
Use this form to evaluate canine behavior, memory-related changes, and follow-up needs. The exact form title must remain consistent throughout the form.
Dog Profile
Dog Name
*
Age (Years)
*
Breed
*
Sex
*
Male
Female
Unknown
Cognitive Assessment
Overall cognitive concern
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Common behaviors observed over time
*
Rows
Never
Occasionally
Often
Very Often
Disorientation
1
2
3
4
Changes in sleep/wake patterns
5
6
7
8
Altered social interaction
9
10
11
12
House-training changes
13
14
15
16
Reduced activity level
17
18
19
20
Response to cues
21
22
23
24
Overall trend of changes
*
Improving
Stable
Worsening
Notable examples or observations
Follow-up Details
Observation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Next Step
*
Review results
Schedule follow-up
I will contact later
Submit Assessment
Should be Empty: