REPORT DATE
(YYYYMMDD)
PRISONER BACKGROUND SUMMARY
SECTION 5 - MENTAL/PHYSICAL HEALTH BACKGROUND
(DETACH THIS PAGE AND MAINTAIN IN THE PRISONER'S MEDICAL RECORDS.)
1. NAME
2. REGISTRATION NUMBER
(Last, First, Middle)
3. HOW WOULD YOU DESCRIBE YOUR CURRENT PHYSICAL CONDITION?
FAIR
POOR
EXCELLENT
GOOD
4. LIST ANY PAST SERIOUS ILLNESS, INJURY OR PHYSICAL AILMENT YOU HAVE SUFFERED OR ARE CURRENTLY SUFFERING AND
DATE OF OCCURRENCE
5. DO YOU HAVE A PHYSICAL HANDICAP?
NO
YES (Explain)
6. LAST HIV TEST DATE
(YYYYMM)
7. HAVE YOU EVER BEEN HOSPITALIZED IN A MENTAL INSTITUTION?
NO
YES (State facility, reason and date)
8. HAVE YOU EVER CONSIDERED SUICIDE?
NO
YES (Explain)
9. HAVE YOU EVER ATTEMPTED SUICIDE?
NO
YES (Explain)
10. PERSONAL HABITS
ALCOHOL USE CLAIMED:
NONE
OCCASIONAL
MODERATE
HEAVY
OTHER (Explain)
WAS ALCOHOL ABUSE APPARENT?
NO
YES
HAVE YOU EVER RECEIVED ALCOHOL TREATMENT?
NO
YES (State facility and date)
OTHER (Explain)
DRUG USE CLAIMED:
NONE
OCCASIONAL
MODERATE
HEAVY
DRUG USE APPARENT?
NO
YES
HAVE YOU EVER RECEIVED DRUG TREATMENT?
NO
YES (State facility and date)
NEVER
GAMBLING:
FREQUENTLY
OCCASIONALLY
12. MENTAL/PHYSICAL HEALTH BACKGROUND INFORMATION
a. SPORTS AND HOBBIES
b. SPECIAL SKILLS/ABILITIES
c. NOTES (Is there anything on this form which is not covered that you feel should be brought to the attention of the confining facility?)
DD FORM 2710, MAR 2013
Page 5 of 5 Pages