Senior Canine Cognitive Assessment Form

All required fields are marked {*}

PLEASE SELECT A LOCATION:*
- Lake Minnetonka Pet Wellness Center: in Navarre next to Dairy Queen
- Westonka Animal Hospital: In Mound Marketplace near Jubilee
DISHAA is a tool to help you and veterinarians assess the mental acuity of your dog, and for veterinarians to potentially diagnose Cognitive Dysfunction Syndrome (CDS).
Date*
MM slash DD slash YYYY
Owner's Name:*
First Last
Owner's Email:*
Pet's Name:*
Pet's Age:*
Gender:*
- Male
- Female
Neutered/Spayed*
- Yes
- No
Breed:*
Weight:*
Current Diet:*
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 0=none, 1=mild, 2=moderate, 3=severe
Gets stuck, difficulty getting around objects, goes to hinge side of door*
Stares blankly at walls, floor, or into space*
Does not recognize familiar people/familiar pets*
Gets lost in home or yard*
Less reactive to visual (sights) or auditory (sounds) stimuli*
Social Interactions
More irritable/fearful/aggressive with visitors, family or other animals*
Decreased interest in approaching, greeting or affection/petting*
Sleep /Wake Cycles
Pacing/restless/sleeps less/waking at night*
Vocalization at night*
Housesoiling, Learning and Memory
Less able to learn new tasks or respond to previously learned commands/name/work*
Indoor soiling of urine or stool/decreased signaling to go out*
Difficulty getting dog's attention/increased distraction/decreased focus*
Activity
Decrease in exploration or play with toys, family members, other pets*
Increased activity including aimless pacing or wandering*
Repetitive behaviors, e.g., circling, chewing, licking or star gazing*
Do you have any mobility concerns for your pet?*
- Yes
- No
Anxiety
Increased anxiety when separated from owners*
More reactive/fearful to visual (sights) or auditory (sounds) stimuli*
Increased fear of places/locations (e.g., new environments/going outdoors)*
Total
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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.

A score of 4-15 is consistent with mild, 16-33 is moderate, and >33 is severe CDS.

Senior Canine Cognitive Assessment Form

Behavioral Signs

Social Interactions

Sleep /Wake Cycles

Housesoiling, Learning and Memory

Activity

Anxiety

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