Brooks Labradors

Diabetic Alert Dog Questionnaire

Brooks Labradors LLC Diabetic Alert Dog Program Questionnaire

Please type your answers directly into this document.

1. Name of applicant:(required)
2. Complete Address:(required)
3. Phone number we can contact you at:(required)
4. Email(valid email required)
5. Is this dog for you or a family member? Me Family Member (required)
6. Age of the person the dog would be for:(required)
7. Do you have pets in the home? Yes No (required)
8. If so, what type of pets and how many of each?
9. For dogs or Cats please give the age of the animals and whether they are spayed or neutered:
10. Dog or Cat? None Dog Cat
11. Age:
12. Spay/Neutered: N/A Yes No
13. Dog or Cat? None Dog Cat
14. Age:
15. Spay/Neutered: N/A Yes No
16. Dog or Cat? None Dog Cat
17. Age:
18. Spay/Neutered: N/A Yes No
19. Have you ever owned a service dog before? Yes No (required)
20. If yes, from whom did you obtain the dog?
21. Please describe your lifestyle (work or trade, activity level, social interactions such as club meetings):
22. Will your dog accompany you to work or school outside your home? Yes No (required)
23. What modes of transportation do you typically use to commute to work or school?(required)
24. Describe where you live (Check what applies):
25. Neighborhood City Country Farm House Apartment Townhouse One story Two story Tri level Fenced yard Access to grassy or wooded area Paths or sidewalks to walk your dog Dog Park nearby
26. How many adults & children live with you?(required)
27. What are the ages and relationships to you of the people you live with?
28. Age:
29. Relationship:
30. Age:
31. Relationship:
32. Age:
33. Relationship:
34. Age:
35. Relationship:
36. Age:
37. Relationship:
38. Age:
39. Relationship:
40. Do any of these people have disabling medical conditions including Type 1 or 2 diabetics? Yes No (required)
41. If so, explain:
42. Is anyone allergic to dogs in your household? Yes No (required)
43. Have you discussed getting a DAD with your medical advisor? Yes No (required)
44. How did you discover the Brooks Labradors Diabetic Alert Dog program?