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~: <br />Soaking r-: <br />Date/Jilme: , <br />$ookin6 Officer: _ <br />ORANGE COUNTY SHERIItF'S OFFICE <br />Inmate Medics! Screening Report <br />Inmate: <br />Race: Ses: DO$: <br />Date/fhne <br />11/058002 <br />SSN: <br />Reviewed By (Nurse): Date: 17me: <br />Q. # Question Answer Notes <br />1 Ts this a Federal Inmate (]`FS) State Inmate (NO) Y <br />2 Please type the Federal Inmate numbs USM# Y <br />3 Do you have any health problwrs including: diabetes, high blood prusure, Y <br />heart disease, mental health, preg~aancy? <br />4 Have you ruently or in the past received mental health carol Have you tried N <br />to harm yourself or kill youtse127 Where did you receive hratment7 <br />5 Are you taking any medications, either prescription or over the counter? List Y <br />6 Do you have any injuries, cuts, bruises, open sores? N <br />7 Do you Gave any artifiral le&a, arms, eyes, glasses, contacts, hearing aids, or N <br />dcntures7 <br />8 Have you ever bad sew? What was the cause? <br />9 Havo you bem treated for drug or alwhol withdrawals? Had blackouts?. <br />DTs7 <br />]0 Do you have tuberculosis, TB, or ever been treated or tested for TB, <br />tuberculosis? Yes, Dates end Locations. <br />I 1 Do you have or think you have any other contagious diseases? <br />12 Do yon have nay allergies to food or racdiciaes? <br />13 (Officer Observation} Does the booking officer observe any injuries? <br />14 (Omcer Observation)- Does the subject appear to be ill, oa Drugs, or <br />Alcohoi7 <br />IS (Officer Observation} Ta the subject able to speak english or understand <br />directions? <br />I6 The medical information I have just given is accurate to the best of my <br />kaflwledge. I am respomrlrk for making nxdical problems known to the <br />medical staff. To see a health care provider, I must sign up for sick call, <br />which is avaIlabk weekdays. I will be-charged a fee fom my inmate account <br />for non-~mergr»sncy side pIl visits. I will not be dartied health care because of <br />a lack offunds, Limited death care is also on available. The Orange County <br />Jail is not responsible for treating medical conditions requiring elective care <br />or surgery, that were prrscat before admission to the jail. <br />I give my consent for dre .Tail Healtir program to destroy nay <br />medication I brought in 30 days after my releue from this facility. I have <br />read or been read and understand ali of the above information. <br />N <br />N <br />Y <br />N <br />N <br />N <br />N <br />Y <br />Y <br />ATTACHMENT #I <br />