Applicant Medical History Form
This form is to be completed
by your physician and sent together with your other application materials to
Canine Co-Pilots.
|
Dr.______________________________________, Please release the requested
information regarding my condition to the above identified organization. This information will help determine my
abilities in regards to the placement of an assistance dog. Additionally, I
give authorization to Canine Co-Pilots’ staff to speak directly with my
doctor. Applicant’s Name
(Print):___________________________________________ Applicant’s Signature:___________________________________Date:_______ |
Doctor’s Name:_____________________________________________________________
Type of Practice:____________________________________________________________
Address:__________________________________________________________________
City:
Phone:______________________________ Fax:____________________________
Patient Information:
What is this patient’s
primary disability?_________________________________________
What was the cause of the
disability?____________________________________________
Are there significant secondary disabilities? Yes No
If yes, please describe:__________________________________________________
At what age was (s)he
disabled?____________ Is this
disability progressive? Yes No
Is there an incapacity due to
or affected by alcoholism or drug abuse? Yes No
Circle all that apply:
What are the effects of the
patient’s disability?
Hearing
loss Speech impairment Reduced Stamina Coordination Problems
Memory
loss
Spasticity Slowed development Vision impairment
Muscular
Weakness Other:____________________________________
Does patient have any
problems with...
Allergies Chronic pain Heightened emotions Depression Balance
Seizures Skin sensitivity Brittle bones Heat/cold sensitivity
Does patient use an aid or
assistive device?
Prosthesis
Leg brace Power Wheelchair Manual Wheelchair
Wrist
brace Hearing Aid Crutch/Cane
Current number of hours of
attendant care per week:__________________________________
Does patient...
Drive
Ride buses Fly
Driven by others Travel
distances on foot/wheels
ADL= Activities of Daily
Living
Is this patient: Please
Circle Below
A. Able to
exercise judgment and make decisions
necessary for ADL? YES
Minimally NO
B. Able to sustain an attention span? YES
Minimally NO
C. Manifesting inappropriate behavior beyond
his/her control? YES
Minimally NO
D. Able to control physical and motor movement
sufficient to sustain ADL? YES
Minimally NO
E. Capable of perception and memory to the
degree
necessary to sustain ADL? YES
Minimally NO
F. Able to follow directions and learn to the
degree
necessary to sustain ADL? YES
Minimally NO
G. Under medication which impairs physical or
mental functioning? YES
Minimally NO
H. Capable of decisions concerning self and
others
needs and safety? YES
Minimally NO
Can you recommend this individual for an assistance
dog? YES
NO
Do you feel the assistance
dog program might benefit from
a consultation with you? YES NO
Comments:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Physician Signature:__________________________________________
Date:______________
Canine Co-Pilots
8539 E. Musket Trail