Measuring the Impact of Our Dogs

Service Dog Program Assessment

To be completed only by recipients of our service dogs.

Please answer every question. Unless otherwise noted, select one response per line. Timeframe instructions (e.g., “past 2 weeks”) are included in each section.

A. Participant

Name:

Date:

Age: less than 3030-4950-6465+

Gender: MaleFemaleNon-binaryPrefer not to say

Veteran: YesNo

Primary Condition: PTSDMobilityOther

B. Quality of Life

Over the past 2 weeks, please rate your: (1 = Very Poor, 5 = Very Good)

1. Overall quality of life: 12345

2. Physical health: 12345

3. Emotional well-being: 12345

4. Social relationships: 12345

5. Ability to perform daily activities: 12345

C. PTSD

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire; a physical or sexual assault or abuse; a natural or human-caused disaster; combat; seeing someone be killed or seriously injured; having a loved one die through homicide or suicide.

In the past month, have you…

1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?: YesNo

2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?: YesNo

3. Been constantly on guard, watchful, or easily startled?: YesNo

4. Felt numb or detached from people, activities, or your surroundings?: YesNo

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?: YesNo

D. Depression

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things : Not at allSeveral daysMore than half the daysNearly every day

2. Feeling down, depressed, or hopeless : Not at allSeveral daysMore than half the daysNearly every day

E. Daily Functioning

In the past 30 days, how much difficulty did you have in: (Scale: 1 = None, 2 = Mild, 3 = Moderate, 4 = Severe, 5 = Extreme or Cannot Do)

1. Getting dressed?: 12345

2. Taking care of your household responsibilities such as shopping and chores: 12345

3. Walking a long distance such as a half a mile?: 12345

4. Getting out of your home, both psychologically and physically?: 12345

F. Social Participation

1=Always, 2=Usually, 3=Sometimes, 4=Rarely, 5=Never

1. I have trouble doing all of my regular leisure activities with others: 12345

2. I have trouble doing all of the family activities that I want to do: 12345

3. I have trouble doing all of my usual work (including work around the house): 12345

4. I have trouble taking part in social activities: 12345

Form completed by:

Relationship to dog’s recipient: