LEAGUE FOR PREVENTIVE WORK REGISTRY OF FEEBLE-MINDED
NAME (SURNAME FIRST)
DATE AND PLACE OF BIRTH
NAME OF HUSBAND (OR WIFE)
RESIDENCE
NAME OF FATHER
FIRST AND MAIDEN NAME OF MOTHER
BY WHOM
BASIS OF DIAGNOSIS
WHEN EXAMINED
HOW LONG UNDER OBSERVATION AND BY WHOM
DIAGNOSIS
DATE OF APPLICATION
INSTITUTION
WHEN ADMITTED
WHEN DISCHARGED
DATE OF COMMITMENT BY COURT
INSTITUTION
WHEN ADMITTED
WHEN DISCHARGED
REMARKS
NOTE IF EXAMINER IS A PHYSICIAN OR
REPORTED BY
PSYCHOLOGIST
WHEN HOS PITAL REGISTERS-NOTE IF KNOWN TO
YES
CASE ACTIVE
SOCIAL SERVICE DEPARTMENT
NO
