(1) HISTORY
(a) Informant: (1) Name
(2) Address
(3) Relationship
(b) Patient: (1) Full name
(2) Born, place, date
(3) Sex, race, education
(4) Occupation
(5) Social Security No.
(6) How long in South Dakota
(7) Marital status
(c) Wife/Husband: (1) Name
(2) Address
(d) Father: (1) Full name
(If a minor) (2) Address
(e) Mother: (1) Full name
(If a minor) (2) Address
(f) Next of kin: (1) Full name
(2) Address
(3) Relationship
(g) Legally responsible relative or guardian:
(1) Full name
(2) Address
(3) Relationship
(h) Military service
(i) Previous treatment for mental illness: Give dates and places of treatment, dates of previous hospitalization, etc.
(j) A review of previous behavior or acts which led to involuntary commitment or treatment which are similar or related to the person's present psychiatric condition or status
(2) EXAMINATION
Findings:
(a) Physical condition, including any special test results:
(b) Present mental condition:
(c) Is this patient considered to be a danger to himself? If so, explain:
(d) Is this patient considered to be a danger to others? If so, explain:
(e) Diagnostic impression:
(f) Is the person taking any medication or drugs? List them if known. In your opinion, do these have an effect on the person's current behaviors? If so, explain:
(g) In your opinion, could this person benefit from treatment? If so, please list the least restrictive alternatives:
(h) Signature of qualified mental health professional.
Source: SDC 1939, § 30.0110; SL 1965, ch 146; SDCL, § 27-7-10; SL 1975, ch 181, § 95; SL 1991, ch 220, § 144; SDCL, § 27A-9-11; SL 1995, ch 154, § 2.