PC-MI-50.3 (Rev. 12-2000) PROBATE COURT OF FRANKLIN COUNTY, OHIO LAWRENCE A. BELSKIS, JUDGE ROBERT G. MONTGOMERY,JUDGE IN THE MATTER OF CASE NO. CASE HISTORY OF MENTAL ILLNESS This form is to be completed by the person making application for admission or by any other interested competent person. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Full name of patient Age Race Patient now resides at Occupation Who is responsible for cost of hospitalization? Name and address in full of person to whom correspondence is to be directed Relationship Guardian: Name Address Name and address of family physician Is patient eligible for veterans benefits? Is patient a dependent or spouse of a deceased veteran? How long have you known this person? State what leads you to believe this person is mentally ill If so, state name and S.S.N.: Telephone Number Date of Birth: Month Sex Single Day Married Street Social Security No. Year Widowed City State Place Divorced Zip County Separated When and where last employed 14. 15. When was the first sign of mental illness observed by you? Are there any legal charges pending on patient, or behaviors that could result in legal proceedings? If yes, explain fully 16. 17. 18. Was this person previously stable and well adjusted? Number of previous attacks of mental disorder Has this person been a patient in any hospital, private or public, for the mentally ill, or any other institution? If Yes, state where, and how long? FRANKLIN COUNTY FORM 50.3 - CASE HISTORY OF MENTAL ILLNESS American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 19. Has this person suffered serious physical injury? (Particularly to the head) If yes explain fully 20. Has this person suffered any great traumatic incidences or recent stress? If yes, explain fully 21. Has this person required feeding, seclusion or restraint? If so, explain fully 22. Has this person been addicted to the use of alcohol or drugs? If so, explain fully 23. Is this person? Paralytic Excited Bedridden Depressed Untidy Homicidal Violent Suicidal Destructive 24. If any of the above are true, describe 25. 26. Does this person have any physical defect or deformity? Does patient have any medical illness for which ongoing medication and monitoring is required? If yes, explain fully 27. Is the patient following doctors instructions for treatment? List problems The above information furnished by Address Telephone Number This information is believed to be true to the best of his or her knowledge. Date Signature American LegalNet, Inc. www.FormsWorkFlow.com