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Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Martin County, Florida Page 4

W O R K S H E E T

QUESTIONS ABOUT PATIENT:

Name of Patient: _______________________________________________________________

Address: ______________________________________________________________________

Phone Number:(H)______________________

(W)_________________________________

Place of Employment: ___________________________________________________________

Date of Birth: ______________

Hgt: ________

Wgt: ________

Sex: _____

Race: ___________ Color of Hair: _________________

Eyes: ________________________

Scars, Tattoos: _________________________________________________________________

PETITIONER:

Name: _______________________________________________________________________

Address: _____________________________________________________________________

Phone Number:(H)______________________

(W)__________________________________

Place of Employment: __________________________________________________________

Relationship to Patient: _________________________________________________________

If friend, how long have you known the patient?

_______Yrs _______Mths

Is there any outstanding charges against the patient? ______Yes

______No

Date of Arrest: ___________ Charge(s): ___________________________________________

Is this the first Bakers Act for the Patient? ______Yes

______No

If not, date and place of action: ___________________________________________________

Is there any Probate or Domestic action taking place against the

Patient? ______Yes

______No

If yes, Court date: _________________ JUDGE: ____________________________________

Do you have guardianship over the patient?

______Yes

______No

Is the patient currently taking any type of medication? ______Yes ______No

If yes, list names of medication: __________________________________________________

Has the patient seen a psychologist or physician?

______Yes ______NO

Date last seen: __________ Doctor's Name: ________________________________________

Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Martin County, Florida Page 4