PHYSICIAN S REPORT Patient s Name: Date of Birth:

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Carol Gaines
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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: Acquiring complete medical information is essential in determining if the applicant can complete our program successfully. In addition, the information we are requesting is vital in assessing special needs that could require modification to our program. Please check yes or no for each item in every category and provide explanations when applicable. MEDICAL HISTORY Please answer yes or no and explain when indicated, including details requested as indicated in parentheses. CARDIAC Heart Surgery (type/date) Hypertension Arrhythmia MI (date) CAD SOB Syncope Anemia NEUROLOGICAL Seizures (type/frequency/date of last seizure) TBI (date) Headache/ Migraines (type/frequency) M.S. C.P. (disability) M.R. Stroke (date/residual) ORTHOPEDIC Back Injuries Muscle/Skeletal Disease Fractures (location/ date) Arthritis (type) Chronic Pain Foot/Knee Injuries Shoulder/arm/ wrist injury PULMONARY Asthma SOB Lung Disease Allergies C.P. (disability) Uses O2/ C-Pap 1

2 Patient s name: GI/GU Ulcers Reflux INFECTIOUS DISEASES AIDS HIV Kidney Disease MRSA Liver Gall Bladder Disease Hepatitis (B or C) Rectal Problems Incontinence IBS ENDOCRINE Adrenal Insufficiency Hypothyroidism Diabetes (complete attached sheet) OTHER DISEASES Auto Immune (type) Cancer (date, type) 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) Yes No Explain if Yes Date Attending Physician/Therapist Frequency of Treatment FOR ANY MENTAL HEALTH TREATMENTS LISTED ABOVE Agency/Hospital Address 2

3 Patient s Name: 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 (see attached sheet) *** 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 CURRENT MEDICATIONS: Name of medication Dosage Frequency Route FOOD ALLERGY: RECOMMENDED DIET: 3

4 Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE FAX Mantoux Tuberculin, PPD Skin Test Record Form Patient Information Name: Address: City/Town: Telephone: Home Work Skin Test Information Administrator Name: Date/Time Administered: Arm on which Administered: Manufacturer of PPD Solution: Expiration Date of PPD Solution: Lot #: Results Iduration mm Date/Time of Reading and Adverse Reactions, if any: Name of Reader: Signature: 4

5 Patient s Name: FOR DIABETIC PATIENTS A1C BLOOD LEVEL (DATE) : (Required) DIET: _ ORAL MEDICATIONS: INSULIN TYPE AND SCHEDULE: AM: NOON: PM: HS: SLIDING SCALE COVERAGE: INSULIN PUMP: INSULIN PUMP BASAL RATE: UNITS PER CARBOHYDRATE: DOES PATIENT TEST HIS/HER BLOOD SUGAR INDEPENDENTLY? METHOD USED: SCHEDULE OF TESTING: DOES THIS PATIENT INDEPENDENTLY ADJUST INSULIN COVERAGE AS PER YOUR INSTRUCTION? 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: 5

6 Patient s Name: 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 minutes 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 should should not be able to participate in the described course of instruction. Physician s Signature Date of Exam (required) Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE admissions@guidingeyes.org FAX

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