Service Dog Training Application Part A1 Psychiatric/PTSD

Name
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?
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?
Overall how would you rate your mental health?
Have you felt particularly low or down for more than 2 weeks in a row?
During the past two weeks, how often has your mental health affected your relationships?
Calm and Peaceful
Energetic
Gloomy
Angry
Have you ever been diagnosed with a mental disorder before?
When did you last get your mental health examination done?
Is there a history of mental disorder in your family?
If YES, Please select which of the family members has/had a history of mental illness.
Light physical Activities
Heavy Physical Activities
Have you seen a therapist in the recent past?
Are you currently taking any medications?
How many hours do you sleep per day?
How is your quality of sleep
How often do you feel positive about your life?