Age:    (                )
 Sex:　　(                )
Q1. What is your main disability?　Please check the applicable item.　
a. Spinal Injury    b. Cerebral Palsy    c. Muscular Dystrophy     d. Rheumatism
e. Others(                                           )
Q2.How frequently do you go out.  Please check the applicable item.
   a. Everyday    b. 1-3 days/week   c. 4-6 days/week   d. Seldom
Q3. Do you like or dislike going out?  Please check the applicable item.
   a. I like it      b. I dislike it
Q4. Which image do you have of dogs?  Please check the applicable item.
   a. Favorable   b. Unfavorable
i). If “Favorable”, why? Please check all the applicable reasons for your choice.
   a. They are clever                   b. They become a watchdog  
c. I feel relaxed when with them      d. I can play with them   
e. They cultivate the aesthetic sentiments of Children
   f. They support me mentally         g. Walking with them is cool
   h. Others(                                                                    )
ii). If “Unfavorable”, why? Please check all the applicable reasons for your choice.
   a. They are hard to care for    b. Barking sounds are irritating      c. Smelly
   d. Scary     e. Dirty          f. They shed hair     g. Expensive    
h. They are hard to train for    
i. I feel sorry for dogs that are made to go through training
   j. Others(                                                                    )
Q5. Have you ever kept a dog?  Please check the applicable item.
   a. Yes, presently      b. Yes, I used to      c. No, I haven’t
Q6. Would you or would you not like to have a dog?  Please check the applicable item.
   a. I would      b. I would not
i). What are the reasons? Please write them. 

Q7. Do you know about “ Assistance dogs”?  Please check the applicable item.
a. Yes, I know them very much 
b. Yes, I know them
c. Yes, I know them a little
d. No, I don’t know them
Q8. Have you ever seen assistance dogs directly?  Please check the applicable item.
   a. Yes      b. No
Q9. Which image do you have of assistance dogs?  Please check the applicable item. 
   a. Favorable      b.Unfavorable

i) If “Favorable”, why? Please check all the applicable reasons for your choice.
   a. They are clever   b. They become a watchdog  c. I feel relaxed when with them
   d. I can play with them   e. They take care of me     f. They support me mentally    g. Walking with them is cool
   h. Others(                                                                   )
ii) If “Unfavorable”, why? Please check all the applicable reasons for your choice.
   a. They are hard to take care for     b. Barking sounds are irritating     c. Smelly     d. Scary      e. Dirty          f. They shed hair        g. Expensive     
 h. I feel sorry for dogs that are made to go through training      
  i. I don’t want them to enter places such as food shops
   j. I don’t like the idea of making them work
   k. Others(                                                                   )
Q10. Would you or would you not like to have an assistance dog?  Please check the applicable item.
   a. I would       b. I would not     c. I have it presently 
i) If “Yes”, for what purpose do you need the dog?  Please check all that apply.
   a. For mental support            b. To pick up something I dropped   
c. To guide me anywhere I like    d. To let me know sounds  e. To pull my wheel chair   f. To call help for me   g. To bring things I want   h. To open/close door for me  
 i. To foretell my seizure and warn me
   j. Others(                                                                     )
ii) If “Yes”,  What are the reasons you don’t have an assistance dog now?

iii) If “No”, please check any applicable reasons for your not wanting an assistance dog.
   a. They are hard to care for           b. I don’t want to be taken care of by a dog
   c. People support me      d. I hate dogs      e. Dogs are burden on my life
f. I feel sorry for dogs that are made to go through training
g. I don’t want to go out with a dog
   h. The place I live does not allow me to keep dogs   
   i. Others(                                                                    )
If you have any opinions or impression on my questionnaire, please write them.     
  
After answering the questions, please send this questionnaire to the below address by e-mail.
Thank you for your cooperation.

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Mariko Yamamoto
Azabu University (Japan)
Email: ma0618@azabu-u.ac.jp
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