Case History Of Developmental Disability {50.6}

PC-DD-50.6 (Rev. 12-2016) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF CASE NO. CASE HISTORY OF DEVELOPMENTAL DISABILITY This form must accompany Medical Certificate of State Institution. To be completed by examining physician, deputy or other person designated by the court. 1. 2. 3. Name Sex Single Married Widowed Birthdate Divorced Social Security No. Separated Religion Place of Residence County of legal residence 4. Person designated next of kin: Name Address 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 FRANKLIN COUNTY FORM DD-50.6 - CASE HISTORY OF DEVELOPMENTAL DISABILITY (PAGE 1) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 8. Father's name and address 9. Mother's name and address 10. List any blood relatives who have a history of convulsions, developmental disability or admission to a public or private hospital for mental illness or developmental disability, giving place and date: 11. Did mother have any illness during pregnancy? Yes No If yes, describe. 12. Was baby full term? Yes Describe: No Birth weight Oxygen used? Yes No 13. Was there any difficulty with the birth? Yes No Describe fully: 14. What and when were the first signs of developmental disability noted? Describe fully: 15. 16. 17. 18. 19. 20. At what age did the patient walk? Can patient walk without assistance? Is patient toilet trained? Yes No Describe: Bowels? Describe: Talk? At what age was patient toilet trained for urine? Can patient feed self with spoon? Yes No 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: FRANKLIN COUNTY FORM DD-50.6 - CASE HISTORY OF DEVELOPMENTAL DISABILITY (PAGE 2) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 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 Describe fully: No At what age? 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: 27. Has the patient had the following diseases and immunizations? Disease Measles Mumps Smallpox Diphtheria Whooping Cough Tetanus Polio When patient had disease Dates of Immunizations 28. Check following behavior traits, if present: Fire Setting Aggressive Sexual Misconduct Stealing Combative Withdrawn FRANKLIN COUNTY FORM DD-50.6 - CASE HISTORY OF DEVELOPMENTAL DISABILITY (PAGE 3) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 29. Has patient ever been to school? Yes No If yes, name and location of school What grades? 30. If excluded, give dates and reasons: Special education classes? 31. Has patient ever been tested psychologically? Yes Where tested? No Give dates: 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 addresses: No Please give dates, names and 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. Date Signature FRANKLIN COUNTY FORM DD-50.6 - CASE HISTORY OF DEVELOPMENTAL DISABILITY (PAGE 4) American LegalNet, Inc. www.FormsWorkFlow.com