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Sarpy County
Department of Corrections
INMATE MEDICAL/MENTAL HEALTH INFORMATION FORM
INMATE INFORMATION
FULL LEGAL NAME OF INMATE:
*
DOB:
June 2026
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Today: 6/3/2026
Street Address:
City:
State:
ZIP Code:
FAMILY CONTACT INFORMATION
FAMILY CONTACT NAME:
RELATIONSHIP
Street Address:
City:
State:
ZIP Code:
DAYTIME PHONE:
EVENING PHONE:
PSYCHIATRIST/TREATMENT FACILITY INFORMATION
PSYCHIATRIST (Current or Last Seen)
DATE LAST TREATED:
June 2026
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Today: 6/3/2026
Street Address:
City:
State:
ZIP Code:
PHONE:
FAX:
MEDICAL/MENTAL HEALTH INFORMATION
DIAGNOSIS:
DAYTIME MEDICATIONS:
NIGHTTIME MEDICATIONS:
PAST PROBLEM MEDICATION EFFECTS (ie. side effects, allergies, medication that did not work):
HOW LONG HAS IT BEEN SINCE MEDICATIONS WERE TAKEN?
IS SUICIDE A CONCERN?
NO
YES
IF YES, WHY?
OTHER MEDICAL CONCERNS:
MEDICAL DOCTOR'S NAME:
OFFICE PHONE:
Street Address:
City:
State:
ZIP Code: