Form Psych 1

Form

1980s

2014.172

A patient psychiatric form from the German Hospital

German Hospital

Width: 210mm
Height: 297mm

No

City and Hackney Health District

GERMAN HOSPITAL

Form Psych 1



(A) Patient ADMITTED to WARD F. ………………… Unit No. …………….
(B) Patient TRANSFERRED to WARD F. …………… from WARD …………….

Informal or Sec: 29, 25, 30, other.


On ……………day of…………… 19…………at……………am/pm

SURNAME (Block Letters) ………………………..Sex ……….

OTHER NAMES (in full)....................Religion………….

Place of Birth ……………….. Occupation …………………………

Admitted from: HOME/OTHER {if other please state} ………………………………………………..
………………………………………………………………………………………………………………………………………………….

Name of Nearest Relative (or friend).......................................................................................

Relationship ……………………………………………

Address of Relative of Friend …………………………………………

Telephone No. at Home ………………………….. At Work …………………………………..

General Practitioner: Doctor ……………………………….. Surgery at…………………………..
…………………………………………………………………………………………………………………………………………………..

Source of Admission: G.P. DOM. VISIT, Psychiatrist at O.P, Clinic, Other (please state)
…………………………………………………………………………………………………………………………………………………..


Previous Psychiatric Out-Patient Care: YES/NO
At Hackney/Other (If other, please state)............................................................................

Previous Psychiatric Admission/s:

Hospital……………………………. Admitted…………………Discharged………………………..
Hospital……………………………. Admitted…………………Discharged………………………..
Hospital……………………………. Admitted…………………Discharged………………………..

Previous In/Out-Patient treatment at Hackney Hospital other than psychiatric YES/NO (If yes state dates)

(1) From…………… To………………. (2) From……………. To……………………………………..

Is Patient in Receipt of Pension/Social Security YES/NO



Signature ……………………………………………….

ALL COPIES TO BE TAKEN TO PSYCHIATRIC RECORDS ON COMPLETION


BALL-POINT PEN MUST BE USED