Please be sure your Physician/MD fills out this form in its entirety. If any question does not apply, please How is patient’s diabetes controlled? Insulin …
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CAPABLE CANINE APPLICANT- MEDICAL REPORT
Please be sure your Physician/MD fills out this form in its entirety If
any question does not apply, please have your Physician/MD mark N/A
Patients Name: Date of Exam: DOB:
Address:____________________________________________________________________
_____
Height: Weight:
How long have you been attending/ treating this patient? of Yrs
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
Please list any significant illness, injury, or surgeries in past 5 years
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
Is patient a smoker? ___ Yes ___ No
Does patient have an active or infectious condition, or immune disorder?
____Yes ___No
If yes, please explain/describe:
Is patient following a special medical diet? ___ Yes ___ No
If yes, please provide a copy of diet
Does patient have psychiatric problems? ___ Yes ___ No
If yes, please explain:
Does patient have any sleeping problems? ___ Yes ___ No
If yes, please explain:
If patient uses sleep apnea machine he/she must bring own to GDF
Blindness History
Cause of Blindness:
___ Accident ___ RP ___ Macula Degeneration
___ Glaucoma
___ Cataracts ___ Diabetes ___ Other
Duration of
Blindness:
Blindness is: ____ Stable ____ Progressive
Does patient have prosthesis: ___Yes ___ No
If yes, please explain:
Hearing/ Speech
R: ___ Normal ___ Abnormal
L: ___ Normal ___ Abnormal
If abnormal, what is degree of loss?
___ Total Deafness ___ Loss of Conversational level ___ Other:
Does patient use hearing aides? ___ Yes ___ No
If yes, does device require routine servicing? ___ Yes ___ No
Does patient have speech impediment? ___ Yes ___ No
Allergies
Is patient allergic to:
___ Dog Dander/Fur ____Cats ___ Medication ___
Food ___ Other
Please describe reaction and what precautions or treatment is necessary:
____________________________________
Cardiopulmonary
BP: ___ Pulse: ___
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
Does patient use a nebulizer? ___ Yes ___ No
If so, patient must bring own to GDF
Neurological
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:
Does patient have a coordination problem? ___ Yes ___ No
Does patient have a balance problem? ___ Yes ___ No
Patients gait is: ___ Normal ___ Abnormal
Patients reflexes are: ___ Normal ___ Abnormal
Does patient have a sensory neurological deficit? ___ Yes ___ No
Doctors Comments:
Orthopedic
Does patient have sufficient motion in upper extremities and hand strength
to
work with and control a Capable Canine leash/ harness held in hand?
___ Yes ___ No
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
____________________________________________________
Does patient use prosthetic device to walk? ___ Yes ___ No
Endocrine
Is patient diabetic? ___ Yes ___ No
If yes, is patient: ___ Type I ___ Type II
Is patients diabetes well controlled? ___ Yes ___ No
If no, please explain:
Does patient test own sugar level? ___ Yes ___ No
times per day level needs to be checked: ____________
Patients typical daily blood sugar range: to
When does patient need to contact physician ie bs300
How is patients diabetes
controlled?
Insulin__________________________________________________________________
Type Dosage Frequency
Does patient use insulin pump? ___ Yes ___ No
If yes, does the device require routine maintenance? ___ Yes ___ No
Oral Medication ___________________________________________________________
Type Dosage
Frequency
Diet: ___ Casual ___ Strict
Can patient measure out insulin units? ___ Yes ___ No
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:
Any neuropathy to hands/ feet? ___ Yes ___ No
Is patient receiving dialysis? ___ Yes ___ No
If yes, how often?
Does patient have any lesions or unhealed areas of feet? ___ Yes ___ No
These must be healed prior to coming to GDF
Does patient have any other endocrine disorders? ___ Yes ___ No
If yes, please
explain:
______________________________________________________
Testing
TB/ PPD: ___ Negative ___ Positive
If positive, chest x-ray is required:
Date of x-ray Result
Specialists
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
Source:agingresearch.org
