Form Rfpc - Regional Forensic - Psychiatric Center - Preadmission Contact Page 2
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4PREADMISSION CONTACT
NAME:________________________________________
PSYCHIATRIC/MEDICAL DIAGNOSIS(ES) – Please enter all known conditions
AXIS I
AXIS II
AXIS III
AXIS IV
AXIS V
REASON FOR INCOMPETENCY IF FOUND INCOMPETENT:
__________________________________________________________________________________________________
___________________________________________________________________________________________________
HIGH RISK BEHAVIOR: (Past/Present)
Suicide Attempt(s); Date(s); Method(s)_______________________________________________________________
AWOL History
Self-Mutilative
Homicidal
Anorexic
Self-Abusive
History of Fire Setting
Polydipsia
Assaultive/Destructive
Sexually Aberrant Behavior
PICA
Uncontrolled Seizure Disorder
Other (please be specific)___________________________________________________________________________
_________________________________________________________________________________________________
CURRENT MEDICATIONS: (Psychiatric and non-Psychiatric)
Reason for Medication
Start Date
Takes Meds
Name of Medication
Dosage
Yes/No
If additional space is needed for medication, please continue on page 4
OVER THE COUNTER MEDICATION OR HERBAL SUPPLEMENTS:__________________________________________
__________________________________________________________________________________________________
DRUG ALLERGIES (Specify Reaction): _________________________________________________________________
FOOD ALLERGIES (Specify Reaction):__________________________________________________________________
SPECIAL DIET:_____________________________________________________________________________________
ENVIRONMENTAL ALLERGIES: _______________________________________________________________________
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RFPC 2010-9
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