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Handicapped

 T4 MED1CAL 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:.....Race^a......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.

^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.