Name:
Street Address:
City:
State/Province:
Zip:
Home Phone:
Work Phone:
Fax:
E-Mail:
Date of birth:
Sex:
male
female
Approximate weight:
Approximate height:
What is your marital status:
Place of Employment:
Address:
City:
State:
Zip:
Supervisor:
Primary means of transportation:
Personal vehicle friends/family public trans.
Doctor's name:
Type of practice:
Address:
City:
State:
Zip:
Phone:
Where do you live:
apt
house
dorm
With whom do you live? (check all that apply)
alone
with parent(s)
spouse
kids
roommates
attendants
Number of hours for attendants:
per day per week per month
What is your primary disability?
Please list secondary disabilities, if any:
What caused your disability or disabilities:
How does it affect your life (limitations):
At what age were you disabled?
Is your disability progressive?
Are there any current changes in your disability?
yes
no
If yes, explain:
What are the effects of your disability (check all that apply)?
Deafness
Speech Impairment
Reduced Stamina
Hearing Loss
Limited Mobility
Muscular Weakness
Slow Development
Vision Impairment
Spasticity
Memory Loss
What is the total weight you can lift with your:
Right arm: Left arm:
Do yoh have problems with any of the following (check all that apply:)
Allergies
Chronic pain
Heightened Emotions
Depression
High Blood Pressure
Balance
Skin Sensitivity
Brittle Bones
Heat/Cold Sensitivity
Do you use an aid or assisting device (check all that apply):
Prosthesis
Leg Brace
Wheelchair
Electric Wheelchair
Walker
Crutch/Cane
Hearing Aid
Table for wheelchair
Is your doctor available for a consultation regarding this application?
yes
no
What kind of dog are you looking for?
Service dog
In home skilled dog
Facility dog
Social therapy dog
With your current health, is it safe for you to travel by (check all that
apply:)
Fly
Bus/Public transportation
Drive yourself
Driven by others
Do you currently have a fenced in yard or enclosed area?
yes no
This is the form from the previous page - please fill it out.
Expected
Burdens Perceived Benefits
