MEDICAL HISTORY FORM

Medical Professional

Provider's Name:

Type of Practice:

Address:

City:

State:

Zip:

Phone:

Email Address:

ADL = Activities of Daily Living

Is this patient:

	Yes	Minimally	No
A. Able to exercise judgment and make decisions necessary for ADL?
B. Able to sustain an attention span?
C. Manifesting inappropriate behavior beyond his or her control?
D. Able to control physical and motor movement sufficient to sustain ADL?
E. Capable of perception and memory to the degree necessary to sustain ADL?
F. Able to follow directions and learn to the degree necessary to sustain ADL?
G. Under medication that impairs physical or mental functioning?
H. Capable of decisions concerning self and others' needs and safety?

Additional Info

Is there anything else you think we should be aware of when dealing with this individual or in relation to providing them with a service dog?

YesNo

Please explain:

Provider's Signature

PLEASE NOTE: All applicants are required to submit medical history forms from two treatment providers (psychiatrist, therapist, GP, neurologist, social worker, etc.) whom we then conduct phone consultations with. We customarily schedule these consultations by email. No personal client information will be transmitted over email. Also, please be aware that the applicants acceptance can not be processed until these consults are conducted, so we appreciate you responding in a timely manner.

Please type your name below as your electronic signature to certify that, to the best of your knowledge and belief, the information provided on this form is accurate. If you would rather sign the form by hand, please print this form, sign it and submit it to: Diggity Dogs Service Dogs, 346 Conway St, Greenfield, MA 01301 or scan and email it to applications@indogswetrust.org with a reference to the applicantʼs first name in the body of the email.

Provider's Signature:

Date:

Contact Information