Information Sheet These are accurate copies of the Bland?s screening forms. I have handwritten page numbers at the bottom of the page to explain each of them. Please note blank spaces on ?yes? questions indicate the inmate did not answer. 1. Blank Screening Form (for reference if you can?t read the original) 2. Screening form ?lled out in the intake-07/10/2015-5z32 pm. 3. Medical Screening form ?lled out at intake -07/10/2015- 4. Computerized Screening form ?lled out at Booking pm. 5. Female intake form at Booking Desk 07/10/2015 County Screening Form for Suicide and Medical and Mental Impairments Per Jail Standard ALL Questions SHALL be Completed in Full Immediately Upon Admission of inmate Name: I Date of Birth I I State ID. Number tit known) I i so. it Datei?iime I I Completed I Does arresting ol?cer or any other persan believe that the inmate IS at risk due to medical condition mental illness. mental retardation. or suicide concern? (Circle one or more 'f applicable) Nelning App? :5 Comments I SELF-REPORT QUESTIONS (please elaborate as needed): Any cone 1! med cal problems. recent hospitalizations or serious or concerns about wit'tdrawal?i' I I If female. are you pregnant? Yes No Not Sure Taking Mod cations? No I Have you ever received services for mental health or mental retardation? I I Do you receive a social security check? Mel] I I Have you ever been in special education? YesD hion I I Do you have any previous military service? I I Do you hear any noses or voices that other people don?t seem to hear? YesD Mom I I Have you ever been very depressed? I I Do you tee! this way now? I I Have you had thoughts of k.lling yourself in the last year? I I Are you thirking about killing yourself today? Mom I I Have you ever attempted su cide? when?I:I Why?I i-low?I I Have you experienced a recent less? NDEI I I STAFF OBSERVATIONS (please elaborate as needed}: Does the individual seem {circeall that app-y) confused pro-occupied paranoid. in an unusually good mood. or believes heisl'e is someone else? Is this person?s speech {circle all that ap ply) rapid. hard to understand. hesitant. or childlike? Observed to be under the in?uence of Alcohol? Drugs? Withdrawals? was Observed to have visible Signs oi set harm {i cuts on arms etc YesD Does the screener suspect mental illnessimental retardation? Yes Non If yes. when was a magistrate notll? ed? DateiTime I How? Written Electronic Additional Comments: I This Form is NOT a substitute for a Separate Health Screening Record required under? 273.4 Revised 9i10i2014 0.36.33 "in?rm EN usurp Pa.qu ma?a?nun ?nal nut-n5 ?llwnunn P02 5 shun "Eh ??uu??nu iu? uEn?um .. "aux ukk?uu war?? Huang mpg. 55 . may wannu??e 33535:: ?h-E ?nun??nu 3532 5b 33 Dun? an? m. sum .6 mama 3530 my. 3 Plum: Burp-?J. .1 Hr: ?\m?mz ?gng?m ur?m? ?aw. 1 ill. almm??nl?u \M?i .nm?m Ema .Inn up. ms um.? mu 3 .unnr. nunm rm u? ?human. um? ?um pun.? ?mun .uunrwh Anna um 1.. F?mm -..aunmc m? ??nnu "323 him 33% new um?vf ?uncut-n?u?la an; .. ?nd ?nnm wrxr? mun. J. juz _l ohm; and. m? Murry. T1. Hh?nnb aux. Hr." um Du?. .Nuuw rung-run" Pu? ran" an.? Dan? Luna an." .uhu Edna u. 3mm.? panama null; 0 arm nn vvnnumr?? ?uuLh Lawn. H..m.l.i manuaamm Hannah.? -0. v.5! . 1. D2 In?ux?: I. .. [1 ?n manna" .n .mJ Human. qu? manna .muiuk ?ruin.? ".mwum? mun?? ?$23 mamFImnm Num?an ul..In?: I .lulu. In?. . I. .. .F?wumnl?mk munhuu ?Nuulurl . ?1 u. bin Fm mrnmurm . I..I nail .hm?murnu Mm sch- lit. TEXAS Texas Department of State Health Services Correctional Tuberculosis Program 53111 ptom Screening Facilit} Name: I NCSD Name: at t. Employee Person completing form: ?lm Date 1&9? 5 am: Upon intake. all inmates should be screened for consiszent with tuberculosis. Please ask all inmates during the intake process if the) have any of the listed below. Persons with shoold receix a cheSt x-ray. regardless of skin test result. Inmates or emplollees at ith a 1curttented his?tory of a positit tuberculin skin result should not receive annual chest x-ray s. In lieu of annual jhest x-rays. screening should be performed annually to determine the presence of TB disease. Any rson with should receive a chest x-ray and be evaluated for TB disease. ll? an inmate 0: employee answers yes to any of the following questions, pleas: document the approximate date each started. l. Productive cough for 2 reels or more. Date 2. Persistent eight loss 'ithout dieting. Date 3. PersiStent fet er abet 300 degrees F. Date 4. Night sweats. Date 5. Loss of appetite. Date 6. Swollen glands in neck or elsen here. Date 7. Coughing up blood (be noptysis). Date 8. Shortness of breath. Date 9. Chest pain. Date l0. Headaches, necl: stiffn *55, Date andfor disorientation oicon?asion Notes: . - Chest x-ray referral: Date: Referred to: Sputum collection referral: Date: Referred to: Medical evaluation referral: jlate: Referred to: Inmates that have consistent with TB should be placed in. isolation under negative air pressure until a diagnosis of tuberculdsis can be ruled out. Employees with consistent with TB should be placed on a work stop precaution until a TB diagnosis is ruled out. EFil [242870 SO 026931 BLAND. SANDRA ANNETTE DOB 02(07i1987 Desc Black Female 175 Booked 071102015 8.15 PM Medical Intake 071100015 8 17 PM Of?cer MAGNUS. ELSA Badge ii EM3679 Insurance N0 Carrier Policy Comment TB Test Date Mby Test Results Date Test Read by Reaction x-Rays Ordered by X-Ray Results Treatment ior TB Given No Intake Questionnaire 1. Allergies? No 8. Alcoholism? No 15. OtherConditions? No 2. Asthma? No 9. Mental illness? ND 16. Treatment Info: NM 3. Heart'l'rouble? No 10. Venereal Disease? ND 17. Recent Injuries: Nm 4. Hypertension? No 11. Tuberculosis? ND 18. Trieatment-Recent mm In my: 5. Diabetes? No 12. Attempted Suicide? No 19. Special Needs: NM 6. Epilepsy? Yes 13. Communicable No 20. Pregnant? No INMATE STATES mm?? SHE HAS EPILEPSY 7. Drug Addiction? No 14. Hepatitis? ND Printed on 71132015 at 4 55.53 PM I I Page 1 OH WALLER COUNTY DEPARTMENT answer It a. sum-i 7m Calvit Street - Hempslud. Texas mes (979)826-8282 - (979)826-7781 fax . Female Inmate Intake arm This questionnaire is to be completed by EACH female inmate that gets booked in at the Waller County jail facility Pregnancy Screening is required by Texas Conunission on Jail Standards, and shall be followed. . This is then to be sent to Mediggl f9: entrv into ?e femye inmate's medial ?le. Please Print Clearly: l) at this time, are you pregnant? YES MAYBE YES NO l'F YES: a) Has this been Veri?ed by a doctor? in) Date of last menstrual cycle? (approx) c) How many weeks are you currently? d) What is your eacpeeted delivery date? 2) When was your LAST Prenatal Appointment? f) When is your NEXT Prenatal Appointment? g) Are you HIGH RISK per your doctor? was No h) Who is your ObStelrician? Location? 2) Have you recently given birth months ago)? YES ,1 IF 2E8: a) How long ago was the birth? b) Birth Method? C-Section Vaginal c) Any complications? 3) Are you CURRENTLY on any medication? YES hmught?om home) 4) Are you CURRENTLY under care of YES a) Are you on medication? YES NO b) When is your next appointment? c) What was iagnos With? Inmate Signature: Date: