Berlin, NW 40, Koenigsplatz 6, 16 November 1939
IV g 4178 /39-5100
Telephone:
Dept. Z, I, II, V, VIII 11 00 27
Dept. II, IV, VI
(Unter den Linden 72); 12 00 34
Tel. Address: Reichsinnenminister.
To the Head of the Hospital for Mental Cases
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 Average frequency of the attacks
alteration
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)
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