Free Redacted Document - District Court of Delaware - Delaware

Casel‘:O4»cy—OOrS21.i=SLEl·_ Document 69-2 Fl|ediD1L23/2006 Page 1 of ·1 P ‘ ‘ ‘
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HEALl’i·lSFr\TUS- ___. I . _ ‘ . · ‘ ‘ .
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am Wg A Number: _ Race®W H- Other .
°°*°’ 2-2lOl A e; pate or Birth: A sex: t= `
Tlméi A PM 4-. QJ
Allergies: _ Food Handler Approved: YIN
Cunent Acute Conditi ns/Probl · -
Chronic Conditions! Problems:
I Current Medications -— Name, Dosage, Frequency, Duration:
_ _ i Acute Short—term Medications: ~
Chronic_Long—term Medications: *4 H mm _ yy __ —_ · _ _
- ""—r `·—-·1¤¤i’ Y. I` - `
_ " ° |•t•9 =• l n. _ ____
A Current Treatm ts:
Follow-up Care Needed: E Q ; E Q ·
Last PPD: Jac Results mms Last Physical: l l
Chronic Clinics: C)-¤.» Specialty Referrals:
Slgnilicant Medical History: • .'
n Physical Dlsabllitiesltlmitationsz ‘ g
Assistive Devices/Prosthetics: — Glasses: Contacts:
_ Mental Health HistoryIConcerns:
Su tance Abuse: Ylig} Alcohol: Y@ Drugs: Y®
Hx Suicide Attempt: Date: __/_/___ rl "·— y
Hx Psychotropic Medication _ , { - » · 07
Previous Psycluagc Hospitalizations _ t = ¤·¤Tl¤¤ _ ¤¤t¤=......J.gT _
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- S. -_ M . • v tz LW P; Di$pcsltior{v·,¤·uc1lons: Check or clrcleasappmprlaiél
' y _ Routine, Sick Call
. . _ `_ , Instructions Given
`.’mr¤!m .l.l.|.|kI|.ll!__._ Emergency Referral
- -—- e—- j HlW'l'B Instruction Given
——— — 1 Physician Referral:
· · Urge I Routine
O: hysicalltppearan _ ehavior: lull JV Medication Evaluation
A r Workl'Program_Llmltation i
______ Special Housing
. ‘ Specialty Referrals
Deformlties: Acute/C2onl5:(E lam; 7/ $;'§t;:°H(2;?l:$
OTHER A .
B P i
A_T··*·· *3* ‘—‘ I */1- y Infirmary Placement
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