Applicant Medical History Form printable pdf download

Applicant Medical History Form

This form is to be completed by your physician and sent together with your other

application materials to Canine Assistants.

Information Release:

Dr. __________________________,

Please release the requested medical information regarding my condition to the above

identified organization. This information will be used to help determine my abilities in

regards to the placement of an assistance dog.

Applicant's Name (please print):______________________________________________

Applicant's Signature:______________________________

Date:___________________

Doctor's Name:___________________________________________________________

Type of practice: _________________________________________________________

Address:________________________________________________________________

City:___________________ County:_________________ State:________ Zip:________

Phone:______________________________

Fax:________________________________

Patient Information:

What is this patient's primary disability?______________ _________________________

What is the cause of this disability?_______________________________ ____________

Are there significant secondary disabilities?

( ) Yes ( ) No

If yes, please describe: _____________________________________________________

At what age was he/she disabled?_________ Is this disability progressive? ( ) Yes ( ) No

Is there an incapacity due to alcohol or drug abuse?

( ) Yes ( ) No

Applicant Medical History Form