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Service Dog Training Application Part A1 Psychiatric/PTSD
Home
Service Dog Training Application Part A1 Psychiatric/PTSD
Service Dog Training Application Part A1 Psychiatric/PTSD
Paws for Life USA
2023-08-15T20:46:19-04:00
Service Dog Training Application Part A1 Psychiatric/PTSD
Name
First
Last
Email
Date
MM slash DD slash YYYY
During the past 4 weeks have you had any problems with your work or dailylife due to your physical health?
Yes
No
Don't know
During the past 4 weeks, have you had any problems with your work or daily life due to any emotional problems, such as feeling depressed, sad or anxious?
Yes
No
Don't Know
Overall how would you rate your mental health?
Excellent
Somewhat Good
Average
Somewhat Poor
Poor
Not Sure
Have you felt particularly low or down for more than 2 weeks in a row?
Very Often
Somewhat Often
Not so Often
Not At All
During the past two weeks, how often has your mental health affected your relationships?
Very Often
Somewhat Often
Not So Often
Not At All
How often do you experience the feelings below:
Calm and Peaceful
Never
Once In a While
About Half the Time
Always
Energetic
Never
Once In a While
About Half the Time
Always
Gloomy
Never
Once In a While
About Half the Time
Always
Angry
Never
Once in a While
About Half the Time
Always
Have you ever been diagnosed with a mental disorder before?
Yes
No
When did you last get your mental health examination done?
Less than 6 months ago
6 months ago
A year ago
More than a year ago
Is there a history of mental disorder in your family?
Yes
No
If YES, Please select which of the family members has/had a history of mental illness.
Mother
Father
Sister
Grandfather
Grandmother
Other
Does your health limit you in doing the following daily activities?
Light physical Activities
Very Less
Moderately
Very Much
Most of the time
Heavy Physical Activities
Very Less
Moderately
Very much
No problem
Have you seen a therapist in the recent past?
Yes
No
Are you currently taking any medications?
Yes
No
How many hours do you sleep per day?
Less than 4
4-6
7-9
9+
How is your quality of sleep
Very bad
Bad
Normal
Good
Very good
How often do you feel positive about your life?
Never
Occassionally
Frequently
All the time
If there is any other info you think we should know please add it here.
Email
This field is for validation purposes and should be left unchanged.
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