The DOGtor.net Online Medical Questionnaire

The following medical questionnaire is desgined to give the approving licensed medical professional a better understanding of who you are, and your past and/ or present mental health, to see if an Emotional Support Animal and/ or Psychiatric Service Dog will be a helpful form of treatment for you. Each question MUST be answered. If the question does not apply to you, answer “No” or “None” in the appropriate field. If a question is left blank, you will not be able to submit the medical questionnaire to be reviewed. Please allow 24-48 hours for your results and to receive your Emotional Support Animal and/ or Psychiatric Service Dog letters if approved. If you are not approved by the licensed medical professional, you will receive a 100% REFUND immediately.

Part I: Personal Information








  • Please answer YES or NO to all questions, write complete answers when requested, and answer “Unsure” if you do not know.

Part I: Personal Information




Question 3. Impact on Major Life Activities Is
there one or more major life activity that you are unable to
perform (or have great difficulty performing)because of problems
caused by stress or any other emotional problem? (Major Life
Activities include, but are not limited to, caring for oneself,
performing manual tasks, seeing, hearing, eating, sleeping,
walking, standing, lifting, bending, speaking, breathing, learning,
reading, concentrating, thinking, communicating, and working).*







Part III PTSD Please
write complete answers when requested and type Yes or No to
all questions or write “Unsure” if you do not know. Question
9. Have you
ever been exposed to a traumatic event in which your life or
someone else’s was actually in danger or you


thought your life or someone else’s was in danger?*




Question 10.
Did you experience feelings of intense fear or helplessness
after the event?*




Question 11.
Have you had recurrent unwanted recollections of the traumatic
in last 6 months – including thoughts, dreams or perceptions?*




Question 12.
Have you ever had flashbacks or feelings you were reliving the
traumatic event even while you’re awake?*




Question 13.
Do you have intense feelings of distress or anxiety when reminded
of the traumatic event?*




Question 14.
Do you try to avoid people or places that remind you of the
traumatic event?*




Question 15.
Do you try to avoid conversations or thoughts that remind you
of the traumatic event?*




Question 16.
Since the traumatic
event have you been much more alert or looking out for possible
trouble?
*




Question 17.
Since the traumatic event took place have you had difficulty
concentrating?*




Question 18.
Since the traumatic event have you felt irritable or had outbursts
that you had difficulty controlling?*




Question 19.
Since the traumatic event took place do you have difficulty
sleeping?*




Question 20.
Since the traumatic event took place are you less interested
in activities you previously enjoyed?*




Question 21.
Since the traumatic event took place have you had difficulty
meeting new people?*




Question 22.
Do reminders of the traumatic event cause physical symptoms
of distress, such as trembling, shortness of breath, increased
pulse, muscle aches, or sweating?*




Question 23.
Do you feel your future life may be negatively impacted as a
result of the traumatic event?




Question 24.
Since the traumatic event took place have you had difficulties
showing emotions of love or affection?




Question 25.
In the last 90 days how often have you been bothered by your
emotions/symptoms from the traumatic event (rarely, Moderately,
Often, Very Often, or None of the Above)




Question 26.


Do the unwanted thoughts or feelings related to the traumatic
interfere with any major life activity (Major Life


Activities include,
but are not limited to, caring for oneself, performing manual
tasks, seeing, hearing, eating, sleeping, walking, standing,
lifting, bending, speaking, breathing, learning, reading, concentrating,
thinking, communicating, and

working.)




Part IV GAD


Please write complete
answers when requested and type Yes or No to all questions or
write “Unsure” if you do not know. QUESTION
27. During the
past six months have you been frequently worried about big or
small events in your

life?*




If you answered Yes above, how frequently has your worrying
caused anxiety or stress in the last six months on a daily basis(more
frequently), several times each week(frequently), only a few
times each month or less, or None)



QUESTION 29.
Do people ever say you worry about things too much?*



QUESTION 30.
Do you think you worry about things too much?*



QUESTION 31.
Do you have difficulty controlling your worries or anxiety?*




QUESTION 32.
How long have you had difficulty controlling your worries in
the past 12 months?




QUESTION 33.
When worried do you frequently feel irritable or on edge for
no apparent reason?




QUESTION 34.
Do you often worry something bad is going to happen to you or
someone close to you?*



QUESTION 35.
When worried do you have frequently have difficulty sleeping?



QUESTION 36.
When worried do you have tensions or muscle aches?




QUESTION 37.
Do you often become tired easily or experience a sudden unexplained
loss of energy?*




QUESTION 38.


Does your worrying interfere with any major life activity? (Major
Life Activities include, but are not limited to, caring
for oneself,
performing manual tasks, seeing, hearing, eating, sleeping,
walking, standing, lifting, bending, speaking, breathing,


learning, reading, concentrating, thinking, communicating, and
working.)




Part V. PD


Please write complete
answers when requested and type Yes or No to all questions or
write “Unsure” if you do not know. QUESTION
39. Have you
ever experienced sudden and unexpected intense fear or anxiety
for no apparent reason (panic attack) or in


situations where you did not expect it to occur in the past
6 months?*




QUESTION 40.
If you answered yes to #39 how often do these anxiety attacks
occur – on a daily basis (more frequently), several times each
week (frequently), only a few times each month, or None




QUESTION 42.
Do you often worry that these panic attacks will have negative
health consequences – possible heart attack, losing control,
or other debilitating affects?




QUESTION 43.
Do you often worry that you will experience more panic attacks
in the future?




QUESTION 44.
During your last panic attack did you feel your pulse increase
(increased heart rate)?




QUESTION 45.
During your last panic attack did you experience uncontrollable
shaking or trembling?



QUESTION 46.
During a panic attack did you often feel dizzy or nauseous?




QUESTION 47.
During your last panic attack did you have difficulty breathing
or feel like you were out of breath?




QUESTION 48.
During your last panic attack did you have hot flashes or experience
profuse sweating?




QUESTION 49.
During your last panic attack did any of your extremities (legs,
fingers, toes, ect.) feel numb?




QUESTION 50.
During your last panic attack did you feel detached from reality,
almost like you were dreaming?




QUESTION 51.


Do your panic attacks or fear of future panic attacks interfere
with any of your major life activities? Major Life


Activities include,
but are not limited to, caring for oneself, performing manual
tasks, seeing, hearing, eating, sleeping,

walking, standing,
lifting, bending, speaking, breathing, learning, reading, concentrating,
thinking, communicating, and


working.




Part VI SSP


Please write complete
answers when requested and type Yes or No to all questions or
write “Unsure” if you do not know.



QUESTION 52.
Do you have an intense fear that you will do or say something
in front of others that will embarrass you?

 




QUESTION 54.
Does your fear in question #53 cause you intense stress or anxiety?




QUESTION 55.
Before, during or immediately after the feared activity in question
#53 do you experience any physical symptoms such as shaking,
trembling, perspiring or nausea?




QUESTION 56.
Have you ever completely avoided the activity in Question #53
because of fear or anxiety?




QUESTION 57.
Does your fear prevent you from performing said activity in
Question #53 or make the task extremely difficult completing?




QUESTION 58.
Do you think you are more afraid or worried than you should
be?




QUESTION 59.
Does the feared activity in question #53 interfere with any
of your major life activities? Major Life Activities include,
but are not limited to, caring for oneself, performing manual
tasks, seeing, hearing, eating, sleeping, walking, standing,
lifting, bending, speaking, breathing, learning, reading, concentrating,
thinking, communicating, and working.




Part VII. MD


Please write complete
answers when requested and type Yes or No to all questions or
write “Unsure” if you do not know.





QUESTION 60.
Do you often feel sad or depressed for unknown reasons?


 *




QUESTION 61.
If you answered yes to #60 how often have you felt sad or depressed
in the last 30
days? On a daily basis
(more frequently), several times each week (frequently), only
a few times


each month, or None




QUESTION 62.
On a typical day how long do your feelings of sadness or depression
persist?




QUESTION 63.
Has your depression or feelings of sadness caused significant
changes in appetite, causing you to eat significantly more or
less?




QUESTION 64.
If you answered YES above, in the last 3 months how long


has your appetite been
increased or decreased ? Very Mild (one week or


less); Mild (one week
to two weeks), Moderate to Severe (two weeks to



one month) Severe (more than one month) or None of the above.




QUESTION 65.
Has your depression caused you to gain or lose a significant
amount of weight (greater than 5%) in any given month?




QUESTION 66.
Have you lost interest in activities you previously enjoyed
because of feelings of sadness or depression?




QUESTION 67.
If you answered YES above, in the last 3 months how long has
your disinterest in
previously interested
activities persisted for? Short term (one week or less); Mild
(one week to two

weeks), Moderate (two weeks to one month) Severe (more than
one month) or None of the above.




QUESTION 68.
Do you often have feelings of worthlessness or often experience
low self esteem




QUESTION 69.
If you answered YES above, in the last 3 months how often have
you experienced feelings of worthlessness or low self-esteem?
Short term (one week or less); Mild (one week to two weeks),
Moderate (two weeks to one month) Severe (more than one month)
or None of the above.




QUESTION 70.
Do you have difficulty sleeping or sleep too much? If so, in
the last 3 months how often
do you experience difficulty
sleeping? On a daily basis (more frequently), several times
each week

(frequently), only a few times each month, or None



QUESTION 71.
Do you often feel fidgety or have problems sitting still?




QUESTION 72.
Do you often feel fatigued or suffer from an unusual loss of
energy? If so how often do you experience fatigue?







QUESTION 73.
Do the unwanted
feelings of sadness or depression interfere with any major life
activity (Major Life Activities include, but are not limited
to, caring for oneself, performing manual tasks, seeing, hearing,
eating, sleeping, walking, standing, lifting, bending, speaking,
breathing, learning, reading, concentrating, thinking, communicating,
and working.)



  

Attention: You must select the plan of your choice and
submit payment in order for your medical exam to be processed.

Choose a Plan:

Compassion Plan

  • Plan Includes No Expiration ESA Housing Letter.
  • Plan Includes No Expiration ESA Travel Documentation.
  • Patients are not required to be re-evaluated.
  • *Most Popular Plan.


$199

Care Plan

  • Plan provides housing ESA documentation only.
  • Plan expires 12 months from date of approval.
  • Upon expiration, patient will be required to be re-evaluated
    by the doctor every 12 months.
  • Does not include travel letter.


$135

Travel Plan

  • Plan is specifically for those who would like a letter to travel
    with their ESA on Commercial Planes, Trains, and Ships.
  • Plan does not include letter for housing.
  • Travel documentation does not expire.


$149

Payment Methods:payment






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