D.A.D. Application

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D.A.D. Application

DIABETIC'S NAME *

DIABETIC'S BIRTHDATE *

YYYY

PARENT OR GUARDIAN IF MINOR

WHAT TYPE OF DIABETES (OR OTHER CONDITION AFFECTING THE REGULATION OF BLOOD GLUCOSE) DOES THE INDIVIDUAL HAVE? *

TYPE 1

TYPE 2

GESTATIONAL

LADA

Other:

DOES THE DIABETIC HAVE ANY OTHER MEDICAL CONDITIONS IN ADDITION TO DIABETES? IF SO, PLEASE LIST ALL. (e.g. Anxiety, celiac disease, thyroid disease. This is necessary because some conditions affect the dogs' abilities to alert.)

WOULD YOU LIKE THE DOG TO BE TRAINED FOR ANY OTHER DISABILITY RELATED TASKS AS WELL, IF POSSIBLE? (ALLERGEN DETECTION, HEARING ALERT, ETC.)

PRIMARY PHONE *

SECONDARY PHONE

EMAIL *

ADDRESS *

CITY *

STATE *

DIABETIC'S AGE *

AGE AT DIAGNOSIS *

DATE OF LAST A1c *

YYYY

RESULT OF LAST A1c *

WHAT IS YOUR GOAL A1c? *

HOW OFTEN IS THE BLOOD SUGAR CHECKED? *

2-4 TIMES PER DAY

4-6 TIMES PER DAY

6-8 TIMES PER DAY

8-10 TIMES PER DAY

10-12 TIMES PER DAY

>12 TIMES PER DAY

HOW IS YOUR BLOOD SUGAR MANAGED? *

INJECTIONS

PUMP

CGM

Other:

Required

AT WHAT NUMBER IS LOW BLOOD SUGAR USUALLY FELT?

SOMETIMES IT IS POSSIBLE TO PREDICT AN OUT OF RANGE BLOOD SUGAR (AFTER A MEAL, EXERCISE, ETC.).HOW REGULARLY DOES AN OUT OF RANGE BLOOD SUGAR READING TAKE YOU BY SURPRISE? *

>5 times each day

1-4 times each day

1-7 times each week

A few times each month

A few times each year

ARE YOU LOOKING FOR A DOG TO ALERT YOU TO LOWS OR HIGHS OR BOTH? *

LOWS

HIGHS

BOTH

WHAT RANGE DO YOU WANT TO KEEP YOUR BLOOD SUGAR? *

What numbers would you ideally like the D.A.D. to alert to?

DO YOU LIVE IN A: *

DO YOU HAVE A YARD? *

YES

IF SO, WHAT SIZE YARD DO YOU HAVE?

SMALL (1/4 - 1/2 acre)

MEDIUM (1/2 - 1 acre)

LARGE (1-2 acres)

FARM (2+ acres)

Clear selection

IS YOUR YARD FENCED?

YES

Other:

Clear selection

DO YOU OWN THE HOME YOU LIVE IN? *

YES

PLEASE LIST ALL MEMBERS LIVING IN THE HOME, AS WELL AS THEIR AGES AND RELATIONSHIP TO THE DIABETIC *

PLEASE LIST ANY OF THE FAMILY MEMBERS WHO WORK OR ATTEND SCHOOL, AND WHETHER IT IS FULL-TIME OR PART-TIME. *

DO ANY OF THE MEMBERS IN THE HOME HAVE DOG ALLERGIES? IF SO, WHICH MEMBERS? *

DO ANY MEMBERS HAVE A FEAR OF DOGS? *

YES

DO YOU HAVE ANY PETS CURRENTLY? IF SO, PLEASE LIST THE TYPE OF PETS AND THEIR AGES. IF NOT, PLEASE WRITE "NO PETS" *

DOES ANYONE IN THE FAMILY HAVE EXPERIENCE TRAINING DOGS? IF SO, PLEASE LIST WHO AND WHAT EXPERIENCE (self trained a pet, attended training classes, competed in obedience or agility competitions, etc). *

WHO WILL BE RESPONSIBLE FOR CARING FOR THE D.A.D.? WHO WILL THE DAD ALERT TO (DIABETIC, PARENT, ETC)? *

DOES THE DIABETIC ATTEND EITHER SCHOOL OR WORK? *

SCHOOL

WORK

NEITHER

Other:

Required

WOULD YOU EXPECT THE D.A.D. TO ATTEND SCHOOL, WORK, ETC. WITH THE DIABETIC? *

YES

Other:

HOW MANY HOURS PER DAY WOULD THE D.A.D. BE LEFT ALONE? *

0 HOURS

1-2 HOURS

2-4 HOURS

4-6 HOURS

6-8 HOURS

OVER 8 HOURS

WHAT ACTIVITIES DOES THE DIABETIC PARTICIPATE IN? WOULD YOU EXPECT THE D.A.D. TO ACCOMPANY HIM/HER? *

HOW MANY HOURS PER WEEK ARE YOU WILLING TO SPEND ON CONTINUAL TRAINING OF THE DAD? *

1-2 HOURS

2-4 HOURS

4-6 HOURS

MORE THAN 6 HOURS

Other:

HOW OFTEN WOULD THE DOG ACCOMPANY THE DIABETIC IN PUBLIC *

ALWAYS (as long as they are safe and appropriate)

ALMOST ALWAYS

SOMETIMES

OCCASIONALLY

NEVER (in home Diabetic Alert Dog)

Required

ARE YOU WILLING TO ACCEPT THE FINANCIAL OBLIGATIONS OF A D.A.D. - APPROX $1500/YEAR? (VET BILLS, INSURANCE, LEASHES, COLLARS, VESTS, PRIVATE TRAINER, GROOMING, ETC.) *

YES

ARE YOU AND ALL FAMILY MEMBERS WILLING TO TREAT TO D.A.D. AS A WORKING DOG RATHER THAN A PET? (E.G. FOLLOW STRICT RULES REGARDING THE HANDLING OF THE D.A.D. - SUCH AS ONLY THE DIABETIC FEEDS THE DOG, NO EXCESSIVE PLAY BY OTHER FAMILY MEMBERS, ETC) *

YES

HAVE YOU EVER HAD A SERVICE DOG BEFORE? *

YES

D.A.D.S NEED EXERCISE EACH DAY. WHAT METHOD DO YOU PLAN ON USING TO EXERCISE HIM/HER? (Walking, running, fetch, treadmill, biking, etc.) *

WHO WILL BE EXERCISING THE D.A.D. EACH DAY? *

WE WILL DO OUR BEST TO TRAIN FOR NIGHT ALERTS, BUT NOT EVERY DOG IS CAPABLE OF THEM AND IT ALSO DEPENDS ON THE DOG'S SCHEDULE - DOGS NEED TO SLEEP TOO! DO YOU UNDERSTAND THAT NIGHT ALERTS CAN NEVER BE GUARANTEED? *

Yes

IF YOU HAVE A D.A.D., YOUR DIABETES WILL NEVER BE "INVISIBLE". YOU WILL GET MANY COMMENTS - GOOD AND BAD. SIMPLE THINGS SUCH AS GOING TO THE STORE CAN BECOME A HASSLE. ALSO BE AWARE THAT HAVING A D.A.D. IS MORE LIKE HAVING A TODDLER AND REQUIRES ATTENTION AND SUPPLIES NO MATTER WHAT THE CIRCUMSTANCES. ARE YOU COMFORTABLE WITH THIS? *

YES

Other:

HAVE YOU RESEARCHED D.A.D.S AND WHAT THEY DO? IF SO, ABOUT HOW MUCH RESEARCH HAVE YOU DONE? *

NO, I HEARD ABOUT THEM FOR THE FIRST TIME RECENTLY

YES, I'VE RESEARCHED THEM A LITTLE. (e.g. I KNOW BASIC INFO AND HAVE SEEN SOME TV INTERVIEWS WITH D.A.D. OWNERS)

YES, I'VE RESEARCHED THEM QUITE A BIT (e.g. FOUND A FACEBOOK GROUP, FORUM, ETC.)

YES, I'VE RESEARCHED THEM A LOT. (e.g. FOUND AS MANY FACEBOOK GROUPS, FORUMS, INTERVIEWS, ARTICLES, ETC AS I CAN. I KNOW ABOUT DIFFERENT ALERTS, ACCURACY, DIFFERENT ORGANIZATIONS THAT TRAIN THEM, ORGANIZATIONS WITH BAD REPS, ETC.)

Other:

PLEASE EXPLAIN WHY YOU WOULD LIKE A DAD AND WHAT GOALS YOU WOULD LIKE TO ACHIEVE BY HAVING ONE. FEEL FREE TO ADD ANY ADDITIONAL INFORMATION THAT WOULD ALLOW ME TO GET TO KNOW YOU BETTER, OR ANYTHING YOU BELIEVE IS IMPORTANT FOR ME TO KNOW. *

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