Physician’s Report
We appreciate your valuable input with regards to determining the manner in which we can
provide the best possible service to this client. Please provide your answers after each colon
where applicable. Thank you in advance for your assistance.
Client’s name:
E-mail address:
Mailing address:
Home phone:
Cell phone:
Date of birth:
Insurance:
How long you have attended this patient:
Date of first visit:
Physical Exam
Age:
Height:
Weight:
Gender:
Blood pressure:
Heart rate:
Cause of blindness:
Gait (normal or abnormal):
Sensory (normal or abnormal):
Coordination (normal or abnormal):
Feet (normal or abnormal):
Reflexes (normal or abnormal):
National Office: P.O. Box 151200, San Rafael, CA 94915-1200  (800) 295-4050  www.guidedogs.com
California Campus: 350 Los Ranchitos Road, San Rafael, CA 94903  (415) 499-4000  Fax: (415) 499-4035
Oregon Campus: 32901 S.E. Kelso Road, Boring, OR 97009  (503) 668-2100 Fax: (503) 668-2141
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Medical History
Please answer yes or no as applicable to the following questions.
Integumentary
Skin rash or hives:
If yes, please explain:
Muscular/Skeletal
Amputations:
Back injury:
Dislocations:
Fractures:
Foot/knee Injury:
Arm/shoulder/wrist Injury:
Muscle/skeletal disease:
If yes to any of the above, please explain:
Neurological
Seizures/type/frequency:
Date of last seizure:
Head injury:
Frequent headaches:
Migraines:
Ear disorder:
If yes to any of the above, please explain:
Endocrine
Diabetes/type/years:
HbA1c value/date:
Insulin reactions/severity:
Neuropathy:
Hypoglycemia:
Hyperglycemia:
If yes to any of the above, please explain:
GI/GU
Ulcers:
Reflux:
Kidney/bladder disease:
Liver/gallbladder disease:
Rectal problems:
If yes to any of the above, please explain:
National Office: P.O. Box 151200, San Rafael, CA 94915-1200  (800) 295-4050  www.guidedogs.com
California Campus: 350 Los Ranchitos Road, San Rafael, CA 94903  (415) 499-4000  Fax: (415) 499-4035
Oregon Campus: 32901 S.E. Kelso Road, Boring, OR 97009  (503) 668-2100 Fax: (503) 668-2141
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Pulmonary
Lung disease:
Tuberculosis:
Cough:
Asthma:
Allergies:
O2 Use/CPAP:
If yes to any of the above, please explain:
Mental Health
Diagnosed mental illness:
Depression:
Anxiety:
Dementia/memory loss:
Sleep disorder:
Eating disorder:
Substance abuse/recovery:
If yes to any of the above, please explain:
Cardiac
Heart surgery:
Heart attack:
Hypertension:
Arrhythmia:
Dizziness:
Syncope:
Shortness of breath:
Palpitations:
Anemia:
Blood disorder:
Chronic fatigue:
If yes to any of the above, please explain:
Other
Transplants:
If yes, please explain:
Has the client had any illness or injury requiring a hospital stay in the past 3 years? Yes or no:
If yes, please explain:
Medical history/narrative:
National Office: P.O. Box 151200, San Rafael, CA 94915-1200  (800) 295-4050  www.guidedogs.com
California Campus: 350 Los Ranchitos Road, San Rafael, CA 94903  (415) 499-4000  Fax: (415) 499-4035
Oregon Campus: 32901 S.E. Kelso Road, Boring, OR 97009  (503) 668-2100 Fax: (503) 668-2141
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List any medications, dosage, and approximate start date:
Medication allergies:
Food allergies:
Special diet, if applicable:
Please attach copies of recent lab work and results.
TB/PPD test (negative or positive) and date:
Tetanus (yes or no) and date:
Chest x-ray, if positive (normal or abnormal):
Other Information
Hearing (normal or abnormal):
Hearing aids (yes or no):
If yes, which ear(s):
This is a 2-3 week residential training program that requires sustained cognitive, physical,
emotional and social functioning from 6 am until 9 pm. Students must be reasonably
independent with chronic disease management, and demonstrate normal immunity to
dormitory life. They must be able to walk up to one hour twice a day with their dog, and will
experience a definable pull from the dog in harness on their left side during the walk.
In your opinion, can this individual safely participate in this program with minimal intervention
and assistance? Yes or no:
Date:
Physician’s signature:
Physician’s name:
Specialty:
E-mail:
Address:
Phone:
Fax:
Please return this information to: GDB Admissions Department, P.O. Box 151200, San Rafael, CA
94915-1200, or via email: iadmissions@guidedogs.com. Thank you.
National Office: P.O. Box 151200, San Rafael, CA 94915-1200  (800) 295-4050  www.guidedogs.com
California Campus: 350 Los Ranchitos Road, San Rafael, CA 94903  (415) 499-4000  Fax: (415) 499-4035
Oregon Campus: 32901 S.E. Kelso Road, Boring, OR 97009  (503) 668-2100 Fax: (503) 668-2141
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