Kaufbeuren
or his deputy in Kaufbeuren.
With regard to the necessity for a systemized economic plan for hospitals and nursing institutions, I request you to complete the attached registration forms immediately in accordance with the attached instruction leaflet and to return them to me. If you yourself are not a doctor, the registration forms for the individual patients are to be completed by the supervising doctor. The completion of the questionnaires is, if possible, to be done on a typewriter. In the column “Diagnosis” I request a statement as exact as possible, as well as a short description of the condition, if feasible.
In order to expedite the work, the registration forms for the individual patients can be dispatched here in several parts. The last consignment, however, must arrive in any case at this Ministry at the latest by 1 January 1940. I reserve for myself the right, should occasion arise, to institute further official inquiries on the spot through my representative.
per proxi: Dr. Conti
Certified:
(Sd.) [Illegible]
Administrative Secretary.
| Registration Form 1 | To be typewritten | |
| Current No. | ||
| Name of the Institution: | ||
| At: | ||
| Surname and Christian name of the patient: | ||
| At birth | ||
| Date of birth: | Place: | District: |
| Last place of residence | District: | |
| Unmarried, married, widow, widower, divorced: | ||
| Religion: | Race[[111]]: | |
| Previous profession: | Nationality: | |
| Army service when? 1914-18 or from 1-9-39. | ||
| War injury (even if no connection with mental disorder) Yes/No | ||
| How does war injury show itself and of what does it consist? | ||
| Address of next of kin: | ||
| Regular visits and by whom (address): | ||
| Guardian or nurse (name, address): | ||
| Responsible for payment: | ||
| Since when in Institution | ||
| Whence and when handed over: | ||
| Since when ill: | ||
| If has been in other institutions, where and how long: | ||
| Twin? Yes/No | Blood relations of unsound mind: | |
| Diagnosis: | ||
| Clinical description (previous history, course, condition; in any case ample data regarding mental condition): | ||
| Very restless? Yes/No | Bedridden? Yes/No | |
| Incurable physical illness: Yes/No (which) | ||
| Schizophrenia: Fresh attack | Final condition | Good recovery |
| Mental debility: Weak | Imbecile | Idiot |
| Epilepsy: Psychological alteration | Average frequency of the attacks | |
| Therapeutics (insulin, cardiazol, malaria, permanent result: | ||
| Salvarsan, etc. when?) | Yes/No | |
| Admitted by reason of par. 51, par. 42b German Penal Code, etc. through | ||
| Crime: | Former punishable offenses: | |
| Manner of employment (detailed description of work): | ||
| Permanent/Temporary employment, independent Worker? Yes/No | ||
| Value of work (if possible compared with average performance of healthy person) | ||
| This space to be left blank. | ||
| Place, Date | ||
| Signature of the head doctor or his representative (doctors who are not psychiatrists or neurologists, please state same). | ||
General Sick Transport Company, G.m.b.H.