Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE FAX
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1 Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE FAX PHYSICIAN S REPORT Patient s Name: Date of Birth: Physician s Name: Physician s Address: Telephone: Fax: MEDICAL HISTORY Heart Surgery (type/date) Hypertension Arrhythmia MI (date) CAD SOB Syncope Anemia CARDIAC NEUROLOGICAL Seizures (type/frequency/date of last seizure) TBI (date) Headache/ Migraines (type/frequency) M.S. C.P. (disability) M.R. Stroke (date/residual) Neuropathy Back Injuries Muscle/Skeletal Disease Fractures (location/ date) Arthritis (type) Chronic Pain Foot/Knee Injuries Shoulder/arm/ wrist injury Amputations Prosthetic or orthotic devices ORTHOPEDIC PULMONARY Asthma SOB Lung Disease Allergies Obstructive Sleep Apnea Uses O2/ C-Pap COPD Emphysema Chronic Bronchitis 1
2 Ulcers Reflux GI/GU INFECTIOUS DISEASES AIDS HIV Kidney Disease MRSA Liver Gall Bladder Disease Hepatitis (B or C) Rectal Problems Incontinence IBS Lyme Disease West Nile Virus Herpes Zoster Adrenal Insufficiency Diabetes Type 1 Diabetes Type 2 Hypothyroidism Pituitary Disorder Addison s Disease ENDOCRINE MENTAL HEALTH Diagnosed Mental Illness Psychiatric Hospitalization (date/ diagnosis) Depression Anxiety Dementia/ memory loss Eating Disorder Sleeping Disorder Alcohol/Substance Abuse (Substance/ Date of Sobriety) Auto Immune (type) Cancer (date, type) Organ Transplant OTHER DISEASES Yes No Explain if Yes Date Attending Physician/Therapist Frequency of Treatment FOR ANY MENTAL HEALTH TREATMENTS LISTED ABOVE Agency/Hospital Address 2
3 PHYSICAL EXAM HEIGHT: BLOOD PRESSURE: HEARING (Normal or Abnormal): GAIT (Normal or Abnormal): COORDINATION (Normal or Abnormal): WEIGHT: HEART RATE: HEARING AIDS (Yes or No) (left / right): REFLEXES (Normal or Abnormal): FEET (Normal or Abnormal): PPD TESTING IS REQUIRED FOR ALL STUDENTS WHO PLAN TO TRAIN ON CAMPUS DATE GIVEN: RESULT: POSITIVE RESULT- INCLUDE CHEST X-RAY DATE: READING: DATE OF LAST TETANUS: DATE OF BOOSTER IF NEEDED: EKG TESTING IS REQUIRED FOR ALL STUDENTS 65 YEARS OLD AND OLDER OR IF CARDIAC DISEASE IS NOTED. EKG DATE (Please include report): READING: PLEASE LIST ANY INJURY OR ILLNESS REQUIRING A HOSPITAL STAY IN THE PAST 5 YEARS. Indicate dates/diagnosis/treatments MEDICATION ALLERGY: PLEASE LIST OR ATTACH CURRENT MEDICATIONS: Name of medication Dosage Route Frequency FOOD ALLERGY: RECOMMENDED DIET: 3
4 FOR DIABETIC PATIENTS DOES THIS PATIENT CONSISTENTLY COMPLY WITH: BLOOD SUGAR TESTING INSULIN ADMINISTRATION DIETARY RESTRICTIONS ROUTINE FOOT CARE IS THIS PATIENT ABLE TO: TEST BLOOD SUGAR INDEPENDENTLY ADJUST INSULIN INDEPENDENTLY (PER YOUR INSTRUCTIONS) DIABETIC STATUS STABLE BRITTLE A1C BLOOD LEVEL (DATE): (Required) SCHEDULE OF BLOOD SUGAR TESTING: DIABETES MEDICATIONS: Name of medication Dosage Route Frequency INSULIN TYPE AND SCHEDULE: Name of Medication Dosage Route AM NOON PM HS SLIDING SCALE COVERAGE INSULIN PUMP TYPE AND BASAL RATE: UNITS PER CARBOHYDRATE: FREQUENCY OF HYPOGLYCEMIC OR HYPERGLYCEMIC REACTIONS: HOSPITALIZATIONS OR EMERGENCY VISITS DUE TO UNSTABLE BLOOD SUGAR LEVELS. PLEASE INDICATE DATES: PLEASE INDICATE SECONDARY COMPLICATIONS AND DEGREE OF SEVERITY: 4
5 Your patient has applied to our school for a guide dog. Guiding Eyes for the Blind s three-week residential training program can be stressful at times. The program requires sustained physical, cognitive, emotional, and social functioning from 6am to 9pm, 6 days a week with rest periods and meal breaks. Students are expected to be independent with their health care needs and able to adapt to dormitory life. Students in training walk 30 to 45 minute routes with their dog twice a day, in all but extreme weather conditions. Guide Dogs typically range in size from 50 to 75 pounds, walk at a minimum speed of 1 to 1 ½ miles per hour, and exert a down and forward pull of at least 2 to 3 pounds. While walking, students may experience sudden, brief increases in speed or pull, or be twisted by unexpected tugs to the left or right. Does this individual suffer from any condition(s) limiting the following: standing, walking, carrying, lifting, stooping, squatting, bending or participating in group interactions? Please specify the condition and recommended restrictions, precautions or modifications: Based on my knowledge of this patient and the information provided to me, it is my opinion that this patient can cannot safely participate in the described course of instruction. Physician s Signature Date of Exam (required) Running Guide Consent Guiding Eyes for the Blind, offers a Running Guide program for qualified applicants who are active runners. Students participating in this program will run or jog a minimum of 2 miles, twice a week. Students will be supervised by a Guiding Eyes for the Blind staff member. Please indicate if your patient is medically stable and fit to participate in this program. It is my medical opinion that this patient can participate safely cannot participate safely. Physician s Signature Date Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE admissions@guidingeyes.org FAX
PHYSICIAN S REPORT Patient s Name: Date of Birth:
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York 10598 PHONE 914 243-2216 admissions@guidingeyes.org FAX 914 243-2232 PHYSICIAN S REPORT Patient s Name: Date of Birth: Physician
PHYSICIAN S REPORT SPECIAL NEEDS Patient s Name: Date of Birth:
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York 10598 PHONE 914 243-2216 admissions@guidingeyes.org FAX 914 243-2232 PHYSICIAN S REPORT SPECIAL NEEDS Patient s Name: Date
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