Williamson County Corrections Mental Health Screening Form ‘Booking Intormation Name Date Booked Status Booking ID = ID Number _—Helght Weight Sex Race DOB SN state 1D # 3, Job loss? No 2. Madtal separation? No 3. Death of loves one? No 4. Loss of business? No 5. Arrest of loved one? No 6. Divorce? No 7. Mor franca toss No 8, Fist ime tender? No 8,0 you have any unstal home family problems we should know about? tS, explain, No 10. Have you ever baen n'a mental institon ar had psychic care? 150, explain No 1, Hove you aver altorpted suede? 10, when and where? No “12, Ave you now cnterplating slide? No 913 Have you previously experienced sexual vtimization? No 14, inmate scored as ether porta Wet cr rgh ek predsoron te PREA questonfes No ata ' bate/time: Reviewed by: Date/Time: ‘wiles Signature: Date/Time Jail Report 54 Page | of rit Date 02/28/2019 13:24Williamson County Corrections /Medical Questionnaire ‘Booking infomation Name Date Hooked Status Booking ID.-——D Number _—-Helaht Welght Sex Race oo son state 10 # Madizal Questionnaire information ~ 1. Any compat of sore threat or ether contagious infection? No 2. Ishe-she on a sped dt prescribed by a physician? No 3. Is he-she presently lating medications? No 44 IS he-she under a doctor's care? No 5: Hes hess been hospitalized recently? Its, where and explain? No Does hese havea history of VO or abnormal discharge? No Isnmate allergic to any mesdcations or foods? No 9. Has Inmate fainted of had ahead injury recently? No 10, Te there a history of TB, Hepatus, Epepsy o Diabetes? No 11, Does inmate have a pall dental contion or fle teeth? No 12, Isinmate pregnant? No 13, Is mate on bith cone! ps? No 14, Does inmate have any phys! handicaps? No 415, Does Inmate have other medal condons the jal shouldbe aware of No 46, Does inmate have any other medical-dental insurance? No 17, Wal yu be detoxing? I 0, rom what? No Completes by: | DateTime evened by: Datei Inmate's Sonat: Dateytine: Jail Report $2 Page | of | Print Date 02/28/2019 13:23,