Texas Hearing & Service Dogs

Medical Background Form
Please print this form, sign the authorization below, and have the form completed by your physician.
 
I authorize the release to Texas Hearing and Service Dogs, Inc., the following information regarding my condition. This information will not be used for any purpose other than to evaluate my application for a Hearing or Service Dog to assist me in daily living. Texas Hearing and Service Dogs will keep this information confidential.
Applicant's signature:

 
To the physician completing this report: Texas Hearing & Service Dogs, Inc. greatly appreciates your time and attention in completing this form. We invest $5,000 and six months in training for each Hearing Dog team (person and dog), and $17,500 and one year of training for each Service Dog team, all at no charge to the recipient. Your information is essential for an accurate evaluation of the applicant.
Name of Applicant:
Form completed by:
Title:
Address:
Phone:
Date of last exam:
Length of association with applicant:
Cause of impairment(s):
Secondary:

Prognosis and effect of impairments on applicant's ability to perform Activities of Daily Living (ADL): the ability to meet personal care needs, e.g. feeding, toileting, dressing, etc. as well as the ability to perform tasks necessary for independent services.
 




Please describe applicant's cause of impairment and progress to date in ADL:
 




Please describe areas which you thing applicant needs to improve in, if any (e.g. reducing dependence on particular medication(s), becoming more independent, improving mood/outlook, improving on finishing projects started, etc.):
 




Please list all the medications applicant is currently taking, the dosage (e.g. 25 mg. 2 times per day), and their purpose. This MUST be a complete list. If you need more room, please use additional paper.
 
Medications
  		  Prescribed Dosage
  		  Purpose
 

 
 

 
 

 
 

 
 

 
 

 
 

Mental/Emotional Evaluation of Applicant
  YES NO
Able to exercise judgment and make decisions necessary for ADL.

Able to sustain attention span.

Able to control physical or motor movement sufficient to sustain ADL.

Short term memory intact and functioning.

Able to follow directions and learn to the degree necessary for ADL.

Capable of decisions regarding personal and others' safety.

Under medication which impairs functioning.

Under medication which impairs short-term memory.

Manifests inappropriate behavior.


Is incapacity due to or affected by alcohol or drug abuse?
 

 
If yes, please answer the following:
  Has applicant been accepted in a treatment facility?

  Is applicant capable of rational decisions?

  Is applicant a danger to self or others?

  Has applicant refused treatment?


A Service or Hearing Dog needs daily training and attention, love and care, including periodic veterinary examinations, heartworm medication, flea control, bathing, good nutrition and emergency care. Please answer the following:
  YES NO
Applicant is in charge of his/her environment. (e.g. pays/has control over attendants, manages own finances, would keep dog despite objections by family members.)

Applicant is capable of practicing at least 30 minutes a day and participating in a 1-1/2 to 2 hour training session each week for approximately 4 to 6 months.

Applicant has the maturity and self-motivation to maintain training schedule. (e.g. not quit halfway through training period, follow the trainer's instructions, not expect everything to be done for him or her, speak up with questions.)

Remarks:


Signature:
Date:

Please return completed form to:
Texas Hearing & Service Dogs, Inc., 4803 Rutherglen, Austin, Texas 78749