Locomotory/ambulatory assessment

Select one

No alterations or debilities noted

Modest slowness associated with change from youth to adult

Moderate slowness associated with geriatric aging

Moderate slowness associated with geriatric aging plus alteration or debility in gait

Moderate slowness associated with geriatric aging plus some loss of function (e.g., cannot climb stairs)

Severe slowness associated with extreme loss of function, particularly on slick surfaces (may need to be carried)

Severe slowness, extreme loss of function, and decreased willingness or interest in locomoting (spends most of time in bed)

Paralyzed or refuses to move

Appetite assessment

Select all that apply

No alterations in appetite

Change in ability to physically handle food

Change in ability to retain food (vomits or regurgitates)

Change in ability to find food

Change in interest in food (may be olfactory, having to do with the ability to smell)

Change in rate of eating

Change in completion of eating

Change in timing of eating

Change in preferred textures

Assessment of elimination function

Change in frequencies of "accidents"

Select one

No change in frequency and no "accidents"

Increased frequency, no "accidents"

Decreased frequency, no "accidents"

Increased frequency with "accidents"

Decreased frequency with "accidents"

No change in frequency, but "accidents"

Bladder control

Select one

Leaks urine when asleep, only

Leaks urine when awake, only

Leaks urine when awake or asleep

Full-stream, uncontrolled urination when asleep, only

Full-stream, uncontrolled urination when awake, only

Full-stream, uncontrolled urination when awake or asleep

No leakage or uncontrolled urination, all urination controlled, but in an inappropriate or undesirable location

No change in urination control or behavior

Bowel control

Select one

Defecates when asleep

Defecates without apparent awareness

Defecates when awake and aware of action, but in inappropriate or undesirable locations

No changes in bowel control

Type of bowel if this occurs please

Formed stool

Diarrhea

Mixed

Visual acuity- how well do you think your pet sees?

Select one

No change in visual acuity detected by behavior- appears to see as well as ever

Some change in acuity not dependent on ambient light conditions

Some change in acuity dependent on ambient light conditions

Extreme change in acuity not dependent on ambient light conditions

Extreme change in acuity dependent on ambient light conditions

Blind

Auditory acuity- how well do you think your pet hears?

Select one

No apparent change in auditory acuity

Some decrement in hearing- not responding to sounds to which your pet used to respond

Extreme decrement in hearing- have to make sure your pet is paying attention or repeat signal or go get your pet when called.

Deaf- no response to sounds of any kind

Play interactions- If your pet plays with toys, which situation best describes that play?

Select one

No change in play with toys

Slightly decreased interest in toys, only

Slightly decreased ability to play with toys, only

Slightly decreased interest and ability to play with toys

Extreme decrease interest in toys, only

Extreme decreased ability to play with toys, only

Extreme decreased interest and ability to play with toys

Interactions with humans- which situation best describes that interaction?

Select one

No change in interactions with people

Recognizes people but slightly decreased frequency of interaction

Recognizes people but greatly decreased frequency of interaction

Withdrawal but recognizes people

Does not recognize people

Interactions with other pets- which situation best describes that interaction?

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No change in interaction with other pets

Recognizes other pets but slightly decreased frequency of interaction

Recognizes other pets but greatly decreased frequency of interaction

Withdrawal but recognizes other pets

Does not recognize other pets

No other pets or animal companions in house or social environment

Changes in sleep/ wake cycle

Select one

No changes in sleep patterns

Sleeps more in day, only

Some change- awakens at night and sleeps more in day

Much change- profoundly erratic nocturnal pattern and irregular daytime pattern

Sleeps virtually all day, awake occasionally at night

Sleeps almost around the clock

Is there anything else you think we should know?

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Cognitive Dysfunction Screen

Assessment of elimination function

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