Inmates Name: D.O.B.

Officer: Body#: Date:

Date of Last Incarceration at S.B. County Jail: Last Tuberculin Skin Test.Date:

Given at What Clinic: Positive Reaction: YES NO Date of Last Chest X-Ray:

OFFICERS OBSERVATIONS: Transiator's Name (if used):

I . Was the inmate brought via the hospital by the arresting officer? YES NO If yes, what hospital?


2. Did the inmate enter the jail under his/her own power? YES NO If No, Explain.

3. Is the inmate: conscious alert oriented sleepy confused unconscious ?

4. Does the inmate have visiable sicns of: injury/illness bruises needle marks sweating

shaking bleeding body deformity ? Explain

5. Does the inmate's behavior suggest a danger to self and others? YES NO

6. Does the inmate appear to have psychiatric problems? YES NO Appear Mentally Retarded? YES NO

7. Does the inmate smell of alcohol or have other signs of drug/alcohol intoxication? YES NO

8. Was the inmate combative, aggressive or hostile in receiving YES NO

9. Is the inmate complaining of pain or injury? YES NO If yes, what action did you take?

10. Did the inmate go to the safety cell directly from recieving? YES NO If yes, why?


I . Do you currently have: TB Hepatitis Hemophilia Diarrhea A Communicable Disease

Diabetes Heart Problems Seizure Disorder Venereal Disease ?

2. Do you have any significant health problems of which the jail should be aware? Explain

3. Are you currently under a physicians care? YES NO If yes, Why and With Whom?

4. Do you need to take medication while in jail? YES NO If yes, What..

5. Are you allergic to any medications? YES NO If yes, What'?

6. Have you been in an auto accident or injured your head in the past three days? YES NO Did you seek medical attention? YES NO Explain

7. Will you be withdrawing from any type of drug or alcohol? YES NO What?

8. Do you have alcohol withdrawal seizures? YES NO

9. Do you have Medi Cal Disability V.A. Medical Insurance

10. Do you have any prosthesis with you ? YES NO Circle (i.e. crutches, glasses, contact lenses, dentures, wheelchair, limb)

11. Are you under the care of phychiatrist now? YES NO If yes, Who?

12. Are you feeling suicidal right now? YES NO If yes, Why?

13. Have you attempted suicide before? YES NO If yes, how many times? Why?

By what means? Date of last attempt


1. Are you currently pregnant? YES NO If yes, how many months? Dr.

Date of last appt.

2. Have you given birth or had a miscarrace in the past month? YES NO If yes, explain

3. Are you taking birth control pills? YES NO


Notified Medical/Mental Health: Time:

General Comments:


SH454 (6t94) (Mcd)