Basic Information: For this section, we need some basic information regarding your prescription What is your first name? What is your last name? What is your email address? Enter your phone number to expedite the proces What is your date of birth? Are you a current or former member of the armed forces? Yes No What is your gender? (not the pets!) Male Female Which state are you currently a resident of? Please select state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Do you currently have an animal? Yes No Approximate weight of animal? (ex: 25lbs) What is your animals name? What is your animals breed? During the past two (2) weeks How much (or how often) have you been bothered by the following problems? 1. Little interest or pleasure in doing things? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 2. Feeling down, depressed, or hopeless? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 3. Feeling more irritated, grouchy, or angry than usual? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 4. Sleeping less than usual, but still have a lot of energy? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 5. Starting lots more projects than usual or doing more risky things than usual Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 6. Feeling nervous, anxious, frightened, worried, or on edge? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 7. Feeling panic or being frightened? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 8. Avoiding situations that make you anxious? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs) Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 10.Feeling that your illnesses are not being taken seriously enough? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 11. Thoughts of actually hurting yourself? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 12. Hearing things other people couldn't hear, such as voices even when no one was around? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 14. Problems with sleep that affected your sleep quality over all? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 17. Feeling driven to perform certain behaviors or mental acts over and over again? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 19. Not knowing who you really are or what you want out of life? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 20. Not feeling close to other people or enjoying your relationships with them? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 21. Drinking at least 4 drinks of any kind of alcohol in a single day? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor's prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? Select an option None Not at all Slight-- Rare, less than a day or two Mild Serveral days Moderate-- More than half the days Severe-- Nearly every day During the past two (2) weeks How much (or how often) have you been bothered by the following problems? 1. I was irritated more than people knew. Select an option Never Rarely Sometimes Often Always 2. I felt angry. Select an option Never Rarely Sometimes Often Always 3. I felt like I was ready to explode Select an option Never Rarely Sometimes Often Always 4. I was grouchy. Select an option Never Rarely Sometimes Often Always 5. I felt annoyed. Select an option Never Rarely Sometimes Often Always Symptoms (Continued): This is the final section of your evaluation Question 1: Describe your happiness. Select an option I do not feel happier or more cheerful than usual. I occasionally feel happier or more cheerful than usual. I often feel happier or more cheerful than usual. I feel happier or more cheerful than usual most of the time. I feel happier of more cheerful than usual all of the time. Question 2: Describe your confidence level Select an option I do not feel happier or more cheerful than usual. I occasionally feel happier or more cheerful than usual. I often feel happier or more cheerful than usual. I feel happier or more cheerful than usual most of the time. I feel happier of more cheerful than usual all of the time. Question 3:Describe your sleeping patterns Select an option I do not need less sleep than usual. I occasionally need less sleep than usual.. I often need less sleep than usual. I frequently need less sleep than usual. I can go all day and all night without any sleep and still not feel tired. Question 4: Describe your social skills Select an option I do not talk more than usual. I occasionally talk more than usual. I often talk more than usual. I frequently talk more than usual. I talk constantly and cannot be interrupted. Question 5: Describe your activity levels: Select an option I have occasionally been more active than usual. I have often been more active than usual. I have frequently been more active than usual. I am constantly more active or on the go all the time. I have not been more active (either socially, sexually, at work, home, or school) than usual. Question 6: For Travel Letters - How will your pet be traveling with you? Select an option Travel carrier On my lap At my feet My pet will not be traveling Question 7: Describe the reasons why you need an Emotional Support Animal AND what specific symptoms you are hoping to alleviate by having your ESA with you. Question 8: How has your life been affected or altered by the pandemic? Send
