History Form

The California Canine Academy

California Canine Academy Assistance 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 California Canine Academy/Assistance Dogs, 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. CCA/AD will keep this information confidential.

Applicant's signature:

To the physician completing this report: We greatly appreciates your time and attention in completing this form. We invest $10,000 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. Your information is essential for an accurate evaluation of the applicant.

Name of Applicant:________________________________________

Form completed by:________________________________________ Title: ____________________

Address:___________________________________________ City: ___________________________

State: ______ Zip: _____________ 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

Able to exercise judgment and make decisions necessary for ADL. YES or NO

Able to sustain attention span. YES or NO

Able to control physical or motor movement sufficient to sustain ADL. YES or NO

Short term memory intact and functioning. YES or NO

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

Capable of decisions regarding personal and others' safety. YES or NO

Under medication which impairs functioning. YES or NO

Under medication which impairs short-term memory. YES or NO

Manifests inappropriate behavior. YES or NO

Is incapacity due to or affected by alcohol or drug abuse? YES or NO

If yes, please answer the following:

__________________________________________________________________________________

Has applicant been accepted in a treatment facility? YES or NO

Is applicant capable of rational decisions? YES or NO

Is applicant a danger to self or others? YES or NO

Has applicant refused treatment? YES or NO

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:

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.) YES or NO

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. YES or NO

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.) YES or NO

Remarks: __________________________________________________________________________

__________________________________________________________________________________

Signature: _____________________________________________ Date: _______________________

Please return completed form to:
California Canine Academy/Assistance Dogs, 5659 W. Brooks Rd, Merced, CA 95348