CANINE COGNITIVE DYSFUNCTION QUESTIONNAIRE

Problems that occur due to age-related changes in the brain are referred to as cognitive dysfunction syndrome. Other names include dementia, Alzheimer's and senility. It describes the progressive degenerative disorder within the brain and is characterized by the loss of memory, learning and problem-solving ability. Unfortunately, the condition is gradual and progressive. However, early diagnosis and regular monitoring can help slow the progression of this condition.

We believe in the importance of pet health care and ongoing health monitoring, particularly for senior pets. Your day to day observations are of great importance when it comes to your pet's overall wellness.

Please complete this questionnaire to help us best understand your pet's health needs.


Client Details

BASIC HISTORY

Which of the following behaviors is your pet experiencing?






















How long has your pet displayed these behaviors?





Do you feel the behaviors are occuring more or less frequently?






CURRENT MEDICATIONS

OVERALL HEALTH

By submitting this form, I acknowledge that I am the owner or agent representing the pet named above and that the information here is true and correct.