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Case History Of Mental Retardation 50.6 - Ohio
| Case History Of Mental Retardation Form. This is a Ohio form and can be used in Psychiatric Probate Franklin County (Court Of Common Pleas) . |
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PC-MI-50.6 (Rev. 2-2005) PROBATE COURT OF FRANKLIN COUNTY, OHIO LAWRENCE A. BELSKIS, JUDGE IN THE MATTER OF CASE NO. CASE HISTORY OF MENTAL RETARDATION This form must accompany Medical Certificate of State Institution. To be completed by examining physician, deputy or other person designated by the court. 1. Name Birthdate Social Security No. 2. Sex Single Married Widowed Divorced Separated Religion 3. Place of Residence County of legal residence 4. Name and address of person designated net of kin Phone No. Relationship 5. Name and address of family doctor 6. Name and address of any other doctors, clinics, or hospitals having had contact with this case and the nature of that contact 7. Reason for commitment at this time 8. Fathers name and address 9. Mothers name and address 10. List any blood relatives who have a history of convulsions, mental retar dation or admission to a public or private hospital for mental illness or mental retardation, giving place and date : FRANKLIN COUNTY FORM 50.6 - CASE HISTORY OF MENTAL RETARDATION American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2CASE NO. 11. Did mother have any illness during pregnancy? Yes No If yes, describe. 12. Was baby full term? Yes No Birth weight Oxygen used? Yes No Describe: 13. Was there any difficulty with the birth? Describe fully: 14. What and when were the first signs of retardation noted? Describe fully: 15. At what age did the patient walk? Talk? 16. Can patient walk without assistance? 17. Is patient toilet trained? Yes No Describe: 18. At what age was patient toilet trained for urine? Bowels? 19. Can patient feed self with spoon? Yes No Describe: 20. Can patient dress self (work zipper, button clothes, tie shoes)? Describe: 21. Has patient had serious accidents or injuries? Yes No Describe fully and give age at occurrence: 22. Has patient had serious illnesses or operations? Yes No Describe fully and give age of occurrence: 23. Has patient had convulsions, fainting, blackouts or spasms? Yes No At what age? Describe fully: 24. Is patient presently on medication? Yes No List medication and dosage: 25. List any drugs, which have caused difficulty (allergy): 26. Is there any defect of hearing and vision? Yes No Describe: American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3CASE NO. 27. Has the patient had the following diseases and immunizations? Disease When patient had disease Dates of Immunizations Measles Mumps Smallpox Diptheria Whooping Cough Tetanus Polio 28. Check following behavior traits, if present: Fire Setting Aggressive Sexual Misconduct Stealing Combative Withdrawn 29. Has patient ever been to school? Yes No If yes, name and location of school What grades? Special education classes? 30. If excluded, give dates and reasons: 31. Has patient ever been tested psychologically? Yes No Give dates: Where tested? I.Q. scores, if known: 32. Has patient ever worked for pay? Yes No Describe: 33. Has patient ever lived in place other than his/her own home? Yes No Please give dates, names and addresses: 34. Has patient been told why he/she is being brought to an institution? Yes No The above information furnished by Address Relationship to patient This information is true to the best of my knowledge. Signature American LegalNet, Inc. www.USCourtForms.com
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