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- "Intake/Reception Health Screening Form - Sample" - Montana
"Intake/Reception Health Screening Form - Sample" - Montana
Intake/Reception Health Screening Form - Sample is a legal document that was released by the Montana Department of Corrections - a government authority operating within Montana.
Form Details:
- Released on August 18, 2009;
- The latest edition currently provided by the Montana Department of Corrections;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Corrections.
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2Attachment - SAMPLE FORM
MONTANA DEPARTMENT OF CORRECTIONS
INTAKE/RECEPTION HEALTH SCREENING FORM
Name:
Date & Time Admitted to
A0/JO Number:
Intake/Reception:
DOB:
Date & Time of Screening:
Status:
Previous Commitment: Yes
No
When:
Where:
County Detention:
How Long:
Temp:
Pulse:
Resp:
B.P.:
Ht:
Wt:
Visual Observation (explain any "Yes" answers under "Remarks")
1. Is offender unconscious or have obvious pain, bleeding, injuries, illness or
other symptoms suggesting a
Yes
No
need for emergency medical referral?
2. Is offender carrying any prescribed medication?
If Yes, what?
Yes
No
3. Is there obvious fever or other evidence of infection, e.g., cough, lethargy?Yes
4. Is there evidence of body vermin, rashes, needle marks, jaundice, bruises,
trauma marking, lesions, & etc.?
Yes
No
5. Does offender appear to be under the influence of, or withdrawing from, drugs,
alcohol or an unknown substance?
Yes
No
6. Does offender's behavior or physical appearance suggest the risk of suicide or
assault on staff or other offenders?
Yes
No
7. Is offender's mobility restricted in any way?
Yes
No
8. Is there any presence of body deformity?
Yes
No
9. Mental Status: (Circle appropriate status)
a. Level of consciousness (alert, oriented, lethargic, comatose)
b. Appearance and behavior (neatly groomed, disheveled, bizarre, threatening)
c. Speech and Communication (fluent, mute, loud, rambling)
d. Mood and Affect (depressed, flat, euphoric, normal, angry, irritable)
e. Thought Process (normal train of thought, tangential, confused,
disorganized)
f. Thought Content (normal, strange or odd belief, suspiciousness, auditory
and visual hallucinations present)
Offender Interview (explain any "Yes" answers under "Remarks")
1. Present Medication (if none, so state):
2. Allergies (if none, so state):
3. Ever had: diabetes, seizures, asthma, ulcers, high blood pressure, a heart
condition or a psychiatric disorder?
Yes
No
4. On a special diet prescribed by a physician?
Yes
No
5. Been hospitalized or treated by a physician within the past year?
Yes
No
6. Been exposed to or have a contagious or communicable disease (i.e. AIDS,
Hepatitis, TB, VD, etc.?)
Yes
No
7. Fainted recently or had a recent head injury?
Yes
No
8. Have any dental problems?
Yes
No
9. Have any other medical or mental problems you have not told me about?Yes
No
10. Use alcohol?
What kind?
How often?
Yes
No
How much?
When was the last time?
11. Use drugs?
What kind?
How often?
Yes
No
How much?
When was the last time?
Withdrawal symptoms?
Yes
No
Attachment - SAMPLE FORM
MONTANA DEPARTMENT OF CORRECTIONS
INTAKE/RECEPTION HEALTH SCREENING FORM
Name:
Date & Time Admitted to
A0/JO Number:
Intake/Reception:
DOB:
Date & Time of Screening:
Status:
Previous Commitment: Yes
No
When:
Where:
County Detention:
How Long:
Temp:
Pulse:
Resp:
B.P.:
Ht:
Wt:
Visual Observation (explain any "Yes" answers under "Remarks")
1. Is offender unconscious or have obvious pain, bleeding, injuries, illness or
other symptoms suggesting a
Yes
No
need for emergency medical referral?
2. Is offender carrying any prescribed medication?
If Yes, what?
Yes
No
3. Is there obvious fever or other evidence of infection, e.g., cough, lethargy?Yes
4. Is there evidence of body vermin, rashes, needle marks, jaundice, bruises,
trauma marking, lesions, & etc.?
Yes
No
5. Does offender appear to be under the influence of, or withdrawing from, drugs,
alcohol or an unknown substance?
Yes
No
6. Does offender's behavior or physical appearance suggest the risk of suicide or
assault on staff or other offenders?
Yes
No
7. Is offender's mobility restricted in any way?
Yes
No
8. Is there any presence of body deformity?
Yes
No
9. Mental Status: (Circle appropriate status)
a. Level of consciousness (alert, oriented, lethargic, comatose)
b. Appearance and behavior (neatly groomed, disheveled, bizarre, threatening)
c. Speech and Communication (fluent, mute, loud, rambling)
d. Mood and Affect (depressed, flat, euphoric, normal, angry, irritable)
e. Thought Process (normal train of thought, tangential, confused,
disorganized)
f. Thought Content (normal, strange or odd belief, suspiciousness, auditory
and visual hallucinations present)
Offender Interview (explain any "Yes" answers under "Remarks")
1. Present Medication (if none, so state):
2. Allergies (if none, so state):
3. Ever had: diabetes, seizures, asthma, ulcers, high blood pressure, a heart
condition or a psychiatric disorder?
Yes
No
4. On a special diet prescribed by a physician?
Yes
No
5. Been hospitalized or treated by a physician within the past year?
Yes
No
6. Been exposed to or have a contagious or communicable disease (i.e. AIDS,
Hepatitis, TB, VD, etc.?)
Yes
No
7. Fainted recently or had a recent head injury?
Yes
No
8. Have any dental problems?
Yes
No
9. Have any other medical or mental problems you have not told me about?Yes
No
10. Use alcohol?
What kind?
How often?
Yes
No
How much?
When was the last time?
11. Use drugs?
What kind?
How often?
Yes
No
How much?
When was the last time?
Withdrawal symptoms?
Yes
No
12. Any past history of infections or communicable illness, treatment or symptoms
(e.g., lethargy, weakness, weight loss,
Yes
No
loss of appetite, fever, night sweats) suggestive of such illness.
13. Past history of mental health treatment? When
Why
Where
14. History of suicide attempts or self mutilation?
Yes
No
15. Any current thoughts of suicide?
Yes
No
a. If yes, does offender have a current plan?
Yes
No
b. Does offender intend to act on his or her plan?
Yes
No
c. Does offender state that he or she cannot remain safe until seen by a
Mental Health Clinician?
Yes
No
16. WOMEN:
Are you pregnant?
Yes
No
Date of last menstrual period
Remarks:
Placement Recommendation: (Circle one)
1. General population
2. Emergency treatment
3.
Suicide monitoring
4. Next sick call
5. Isolation
Does the offender require any of the following referrals? (check appropriate and
insert date if applicable)
Routine (all offenders will receive a physical exam or comprehensive nursing
assessment within seven days)
Urgent (offenders appears in imminent danger)
Medication Referral (offenders need incoming meds renewed)
Medical:
Urgent
__________________________
Routine
__________________________
Medication Referral _________________
Dental:
Urgent
__________________________
Routine
__________________________
Medication referral _________________
Mental Health:
Urgent
__________________________
Routine
__________________________
Medication referral
_______________
Administration of PPD:
Date
__________________________
Time
__________________________
Reading
__________________________
OFFENDER HAS BEEN TOLD AND SHOWN IN WRITING HOW TO OBTAIN
MEDICAL SERVICES
SIGNATURE
OFFENDER NAME
copies to:
DOC 4.5.13 (Attachment) Intake/Reception Health Screening – Revised 08-18-09
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