Holocaust Teacher Resource Center

HOLOCAUST TEACHER RESOURCE CENTER
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T4 Medical Questionnaire

Questionnaire 1
Case no……………………………………………………..
Name of Institution:………………………..in:………………
First and family name of patient:…………….maiden name:………
Date of birth:………….City:………………….District:…….
Last Residence:…………………………………District:…….
Unmarr., marr., wid., div.:…..Relig:…..Racea……Natlty:………
Address of nearest relative:……………………………………
Regular visits and by whom (address):……………………………
Guardian or Care-Giver (name, address):………………………….
Cost-bearer:……………….How long in this inst.:…………….
In other Institutions; when and how long:………………………..
How long sick:………..From where and when transferred:………….
Twin yes/no…………..Mentally ill blood relatives:…………….
Diagnosis:……………………………………………………
Primary symptoms:……………………………………………..
Mainly bedridden? yes/no….Very restless yes/no….Confined yes/no….
Incurable phys. illness: yes/no:…….War casualty: yes/no…………
For schizophrenia: Recent case……Final stage…..good remission…..
For retardation: Debility:……….Imbecile:…….Idiot:………….
For epilepsy: Psych. changes……..Average freq. of attacks………..
For senile disorders: Very confused………………Soils self……..
Therapy (Insulin, Cardiazol, Malaria, Salvarsan, etc.):
Lasting effects: yes/no….
Referred on the basis of §51, §42b Crim. Code, etc………By……….
Crime:…………Earlier criminal acts:………………..
Type of Occupation: (Most exact description of work and productivity,
e.g. Fieldwork, does not do much.–Locksmith’s shop, good skhled worker.
–No vague answers, such as housework, rather precise: cleaning room; etc..
Always indicate also, whether constantly, frequently or only occasionally occupied)……………………………………………………………………………………..
Release expected soon:………………………………………………………………….. Remarks:……………………………………………………………………………………..
Do not mark in this Space.

……………………………….
……………………………….
……………………………….
Place, Date………………………………..
……………………………………………….
Signature of medical director or his representative)

aGerman or related blood (German-blooded), Jew, Jewish Mischling (half-breed) 1st or 2nd degree, Negro (Mischling), Gypsy (Mischling), etc.

Translated in Robert J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York, 1986), pp. 68-69.