Diabetic Alert Dog Questionnaire

To apply for a Diabetic Alert Dog (DAD) from Thistle Ridge Terriers, please complete the following questionnaire.

Applicant Name:*

Full Address:*

Phone Number:*

Email Address:*

Is this dog for you or a family member?*

Me Family Member

Age of person the dog would be for:*

Do you have pets in your home?*

Yes No

If so, what type of pets and how many of each?

For dogs and cats, please provide their age
and whether they are spay/neutered:

Have you owned a service dog before?*

Yes No

If yes, from whom did you obtain the dog?

Please describe your lifestyle
(activity level, social interactions):

WIll your dog accompany you to work or school?*

Yes No

What modes of transportation do you use
to commute to work or school?*

Please describe where you live
(Check all that apply):

Neighborhood
City
Country
Farm
House
Apartment
Townhouse

One-story
Two-story
Tri-level
Fenced Yard
Grassy/Wooded Area
Paths/Sidewalks
Dog Park Nearby

How many adults and children live with you?*

What are the ages/relationships to you
of the people you live with?

Age: Relationship:
Age: Relationship:
Age: Relationship:
Age: Relationship:
Age: Relationship:
Age: Relationship:

Do any of these people have disabling medical
conditions including Type 1 or 2 diabetics?*

Yes No

If yes, please explain:

Is anyone allergic to dogs in your household?*

Yes No

Does anyone in your household smoke?*

Yes No

Have you discussed getting a Diabetic Alert Dog
with your medical advisor?*

Yes No

A1c Three Month Average:

How did you discover our organization?