C.M.R. 03, 201, ch. 1, 201-1-II, app 201-1-II a-E
| Inmate's Name Date of Birth Sex Date Time | ||
| Most Serious Charge | Report Number | Screening Officer |
Was inmate a medical, mental health or suicide risk during any prior contact or confinement with your department"
Yes No If Yes, when:____________________________________________________
Does the arresting or transporting officer believe that inmate is a medical, mental health or suicide risk now"
Yes No
OFFICERS' OBSERVATIONS
YES NO YES NO
_____ _____ Assaultive/Violent Behavior ____ _____ Crying/Tearful
_____ _____ Loud/Obnoxious Behavior ____ _____ Confused
_____ _____ Any Noticeable Marks/Scars ____ _____ Uncooperative
_____ _____ Bizarre Behavior ____ _____ Passive
_____ _____ Alcohol/Drug Withdrawal ____ _____ Intoxicated
_____ _____ Unusual Suspiciousness ____ _____ Scared
_____ _____ Hearing Voices/Seeing Visions ____ _____ Incoherent
_____ _____ Observable Pain/Injuries ____ _____ Embarrassed
_____ _____ Other Observable Signs of ____ _____ Cooperative
Depression explain:_______________________________________
MEDICAL HISTORY
YES NO
_____ _____ Are you injured" If Yes, explain:______________________________
_____ _____ Are you currently under a physician's care" If Yes, explain:
_____ _____ If female, Are you pregnant"
_____ _____ Are you currently taking any medication" If Yes, list type(s), dosage(s), and frequency:
__________________________________________________________
DO YOU SUFFER FROM ANY OF THE FOLLOWING:
YES NO YES NO
_____ ______ Hepatitis ____ ______ Heart Diseases
_____ ______ Shortness of Breath ____ ______ Chest Pain(s)
_____ ______ Abdominal Pain(s) ____ ______ Asthma
_____ ______ High Blood Pressure ____ ______ Venereal Disease
_____ ______ Tuberculosis ____ ______ Diabetes
_____ ______ Alcohol Addiction ____ ______ Drug Addiction
_____ ______ Epilepsy/Blackouts/Seizures ____ ______ Ulcers
_____ ______ Other Medical Problems and/or Diseases ____ ______ AIDS (Optional)
explain:_____________________________________________________
SUICIDE ASSESSMENT
YES NO
____ ____ Have you ever attempted suicide" If Yes, When"____________________________________
Why"___________________________________ How"_______________________________
___ ____ Have you ever considered suicide" If Yes,
When"__________________________________ Why"_______________________________
___ ____ Are you now or have you ever been treated for mental health or emotional Problems" If Yes
When"_________________________Inpatient:_________Outpatient:________Both______
____ ____ Have you recently experienced a significant loss (job, relationship, death or family member/
close friend, etc.)" If Yes, explain:
_____________________________________________________________________________
____ ____ Do you feel that there is nothing to look forward to in the immediate future
(expressing helplessness and/or hopelessness)" If Yes, explain:
___________________________________________________________________________
____ _____ Are you thinking of killing yourself" If Yes, explain:_________________________________
Additional Remarks:__________________________________________________
__________________________________________________________________________________________
DISPOSITION
General Population
Special Watch
__________________________________________________________________________________________
Medical Hospital. If inmate is later returned to facility, list any special watch recommendations.
__________________________________________________________________________________________
Mental Health Service. If inmate is later returned to facility, list any special watch recommendations.
__________________________________________________________________________________________
Other dispositoin/referral/transfer__________________________________________________________
FAILURE TO ANSWER/REFUSAL OF TREATMENT
Inmate refused to answer (circle) or unable to answer (circle and state why) the verbal response sections of this screening form.
I, __________________________(print name), refuse any type of medical treatment.
SIGNATURES: Inmate:_________________________________
Screening
Officer:______________________________________ Supervisor:_________________________________
C.M.R. 03, 201, ch. 1, 201-1-II, app 201-1-II a-E