PC-MI-50.6 (Rev. 2-2005) PROBATE COURT OF FRANKLIN COUNTY, OHIO JUDGE ERIC BROWN LAWRENCE A. BELSKIS, JUDGE IN THE MATTER OF CASE NO. CASE HISTORY OF MENTAL RETARDATION This form must accompany Medical Certificate of State Institution. To be completed by examining physician, deputy or other person designated by the court. 1. Name Birthdate 2. Sex 3. Place of Residence 4. Name and address of person designated net of kin Single Married Widowed Divorced Social Security No. Separated Religion County of legal residence Phone No. Relationship 5. Name and address of family doctor 6. Name and address of any other doctors, clinics, or hospitals having had contact with this case and the nature of that contact 7. Reason for commitment at this time 8. Father’s name and address 9. Mother’s name and address 10. List any blood relatives who have a history of convulsions, mental retardation or admission to a public or private hospital for mental illness or mental retardation, giving place and date: FRANKLIN COUNTY FORM 50.6 - CASE HISTORY OF MENTAL RETARDATION American LegalNet, Inc. www.FormsWorkflow.com CASE NO. 11. Did mother have any illness during pregnancy? Yes 12. Was baby full term? Yes No No If yes, describe. Birth weight Oxygen used? Yes No Describe: 13. Was there any difficulty with the birth? Describe fully: 14. What and when were the first signs of retardation noted? Describe fully: 15. At what age did the patient walk? 16. Can patient walk without assistance? 17. Is patient toilet trained? Yes 18. At what age was patient toilet trained for urine? 19. Can patient feed self with spoon? Yes 20. Can patient dress self (work zipper, button clothes, tie shoes)? Describe: 21. Has patient had serious accidents or injuries? Yes 22. Has patient had serious illnesses or operations? Yes 23. Has patient had convulsions, fainting, blackouts or spasms? Yes Talk? No Describe: No Bowels? Describe: No Describe fully and give age at occurrence: No Describe fully and give age of occurrence: No At what age? Describe fully: 24. Is patient presently on medication? Yes No List medication and dosage: 25. List any drugs, which have caused difficulty (allergy): 26. Is there any defect of hearing and vision? Yes No Describe: American LegalNet, Inc. www.FormsWorkflow.com CASE NO. 27. Has the patient had the following diseases and immunizations? Disease When patient had disease Dates of Immunizations Measles Mumps Smallpox Diptheria Whooping Cough Tetanus Polio 28. Check following behavior traits, if present: Fire Setting 29. Aggressive Sexual Misconduct Has patient ever been to school? Yes No What grades? Stealing Combative Withdrawn If yes, name and location of school Special education classes? 30. If excluded, give dates and reasons: 31. Has patient ever been tested psychologically? Yes No Give dates: Where tested? I.Q. scores, if known: 32. Has patient ever worked for pay? Yes No Describe: 33. Has patient ever lived in place other than his/her own home? Yes No Please give dates, names and addresses: 34. Has patient been told why he/she is being brought to an institution? Yes No The above information furnished by Address Relationship to patient This information is true to the best of my knowledge. Signature American LegalNet, Inc. www.FormsWorkflow.com