p Accident p RP p Macula Degeneration p Glaucoma. p Cataracts p Diabetes p Other 34. How is patient’s diabetes controlled? Insulin …
371 E Jericho Turnpike, Smithtown, NY 11787
866 282-8047 Fax 631930-9009 wwwguidedogorg
MEDICAL REPORT FOR GUIDE DOG FOUNDATION APPLICANT
Applicants: This form must be completed by your primary physician
Physician: Your patient has applied for a guide dog to enhance his/her
mobility and independence When completing this form please keep in mind
that the applicant will undergo rigorous training, both mental and
physical They will spend twenty five days training and will be expected
to walk for hour twice daily in all types of weather conditions By
completing this form in its entirety you will assist in determining your
patients needs Please answer every question, writing N/A if the question
is not applicable
The ophthalmologists report and verification of blindness is a separate
form Please fax or mail this back to us in the enclosed self-addressed
envelope Thank you for your assistance and cooperation
1 Patients Name: Date of Exam:
DOB:
Address:____________________________________________________________________
_____
Height: Weight:
2 How long have you been
attending/ treating this patient? of Yrs
3 Please indicate if the patient now has or has had any of the
following:
___ Amputations ___ Rheumatism/ Arthritis ___
Cancer
___ Fractures/ Dislocations ___ Dizziness ___
Varicose Veins
___ Back Injury/ Problems ___ Fainting ___ Depression
___ Shoulder Injury/ Problems ___ Numbness/ Weakness ___ Ulcers
___ Knee Injury/ Problems ___ Severe Headaches ___
Neurological Disorder
___ Swollen Ankles/ Feet ___ Excessive Fatigue
___ Joint Problems
___ Athletes Foot ___ Hernia
___ Kidney/ Urinary Problem
___ Hand/ Wrist Problems
Doctors Comments: Please provide any important details relevant to above
items
4 Please list any significant illness, injury, or surgeries in past 5
years
5 Does patient have a substance abuse problem?
___ Alcohol ___ Controlled Substances
If yes, please indicate if patient is in recovery and for how long?
Patient should be in recovery for 1 year or more
6 Is patient a smoker? ___ Yes ___ No
7 Does
patient have an active or infectious condition, or immune disorder?
____Yes ___No
If yes, please explain/describe:
8 Is patient following a special medical diet? ___ Yes ___ No
If yes, please provide a copy of diet
9 Does patient have psychiatric problems? ___ Yes ___ No
If yes, please explain:
10 Does patient have any sleeping problems? ___ Yes ___ No
If yes, please explain:
If patient uses sleep apnea machine he/she must bring own to Guide Dog
Foundation
Blindness History
11 Cause of Blindness:
? Accident ? RP ? Macula
Degeneration ? Glaucoma
? Cataracts ? Diabetes ?
Other_____________________________
12 Duration of Blindness
___________________________________________________
13 Does patient have prosthesis? Yes ? No ?
If yes, please
explain:______________________________________________________
Hearing/ Speech
14 R: ___ Normal ___ Abnormal
L: ___ Normal ___ Abnormal
If abnormal, what is degree of loss?
___ Total Deafness ___ Loss of Conversational level ___ Other:
15 Does
patient use hearing aides? ___ Yes ___ No
If yes, does device require routine servicing? ___ Yes ___ No
16 Does patient have speech impediment? ___ Yes ___ No
Allergies
17 Is patient allergic to:
___ Dog Dander/Fur ____Cats ___ Medication ___
Food ___ Other
Please describe reaction and what precautions or treatment is necessary:
____________________________________
Cardiopulmonary
18 BP: ___ Pulse: ___
19 Please indicate any pertinent medical conditions:
___ Hypertension ___ Asthma
___ Angina ___ Tuberculosis
___ Congestive Failure ___ Emphysema
___ Coronary or Systemic Ailment ___ Lung Disease
___ Heart Murmur ___ Heart
Attack
___ Stroke ___ Edema
___ Arteriosclerosis ___ Dyspnea
___ Cyanosis
20 Does patient use a nebulizer? ___ Yes ___ No
If so, patient must bring own to Guide Dog Foundation
Neurological
21 Does patient have seizure disorder? ___
Yes ___ No
If yes, please explain Type
Date of last seizure:
Severity of seizures:
Frequency of seizures:
Duration of seizures:
Does patient recognize onset of seizure? ___ Yes ___ No
Date of last hospitalization due to seizure:
Is patient on anti-seizure Rx: ___ Yes ___ No
If yes, date Rx level was last checked:
Result: ___ Normal ___ Abnormal
Are patients seizures well controlled? ___ Yes ___ No
Please explain:
22 Does patient have a coordination problem? ___ Yes ___ No
23 Does patient have a balance problem? ___ Yes ___ No
24 Patients gait is: ___ Normal ___ Abnormal
25 Patients reflexes are: ___ Normal ___ Abnormal
26 Does patient have a sensory neurological deficit? ___ Yes ___ No
Doctors Comments:
Orthopedic
27 Does patient have sufficient motion in upper extremities and hand
strength to work with and control a Guide Dog leash/ harness held in
hand? ___ Yes ___ No
28 Does patient have any limitations to motion in:
___ Back ___ Neck
____________________________________________________
___ Right Shoulder ___ Left
Shoulder
_______________________________________________
___Right Arm ___ Left Arm
__________________________________________________
___ Right Wrist ___ Left Wrist
___________________________________________________
___ Right Leg ___ Left Leg
____________________________________________________
___ Right Foot ___ Left Foot
____________________________________________________
29 Does patient use prosthetic device to walk? ___ Yes ___ No
Endocrine
30 Is patient diabetic? ___ Yes ___ No
If yes, is patient: ___ Type I ___ Type II
31 Is patients diabetes well controlled? ___ Yes ___ No
If no, please explain:
32 Does patient test own sugar level? ___ Yes ___ No
times per day level needs to be checked: ____________
33 Patients typical daily blood sugar range: to
When does patient need to contact physician ie bs300
34 How is patients diabetes controlled?
Insulin__________________________________________________________________
Type Dosage Frequency
35 Does patient use insulin pump? ___ Yes ___ No
If yes, does the device require routine maintenance? ___ Yes ___ No
36
Oral Medication
___________________________________________________________
Type Dosage
Frequency
37 Diet: ___ Casual ___ Strict
38 Can patient measure out insulin units? ___ Yes ___ No
39 Does patient know how to treat insulin reactions? ___ Yes ___ No
Are reactions frequent? ___ Yes ___ No
Date of last hospitalization due to : Hypoglycemic
Hyperglycemia
Has patient ever been in: _____ Insulin shock _____ Diabetic coma
If so, please explain:
40 Any neuropathy to hands/ feet? ___ Yes ___ No
41 Is patient receiving dialysis? ___ Yes ___ No
If yes, how often?
42 Does patient have any lesions or unhealed areas of feet? ___ Yes ___
No
These must be healed prior to coming to GDF
43 Does patient have any other endocrine disorders? ___ Yes ___ No
If yes, please explain:
______________________________________________________
Testing
44 TB/ PPD: ___ Negative ___ Positive
If positive, chest x-ray is required:
Date of x-ray Result
Specialists
45 To the best of your knowledge, is patient seen by any of the following
specialists:
___
Neurologist ___ Cardiologist ___ Orthopedist
___ Rheumatologist ___ Psychiatrist ___
Endocrinologist/
___ Other ___ Diabeteologist
Please provide contact information for all specialists:
Name Telephone
Name Telephone
Name Telephone
Name Telephone
Name Telephone
Medications
Please enclose a list of all medications including over-the-counter that
the patient is currently taking Please include name, dosage, frequency,
and the condition each is used to treat In addition, please describe the
extent to which the patient is advised to self-regulate the dosage or
frequency of the medications
In your opinion, is the patient physically, mentally and emotionally able
to participate in our 25 day training program - Will he/she be able to
walk, at a moderate pace, for approximately one-half to one hour daily,
twice a day in all types of weather? ___ Yes ___ No
If no, please explain:
Physicians Signature:
Date:
Please print physicians name
Address:
Telephone: Fax:
If you have any questions or concerns please call our Consumer Services
Department at 866-282-8047
