<p> INMATE MEDICATION INFORMATION FORM</p><p>INMATE INFORMATION</p><p>FULL LEGAL NAME OF INMATE:</p><p>STREET ADDRESS: ______CITY: ______STATE: _____ ZIP CODE: ______</p><p>DOB: ______</p><p>BOOKING______</p><p>JAIL LOCATION: ______FLOOR: ______</p><p>FAMILY CONTACT INFORMATION</p><p>FAMILY CONTACT NAME: ______RELATIONSHIP ______</p><p>STREET ADDRESS: ______CITY: ______STATE: _____ ZIP CODE: ______</p><p>DAYTIME PHONE: ______EVENING PHONE: ______</p><p>CONTACT SIGNATURE: x______</p><p>PSYCHIATRIST/TREATMENT FACILITY INFORMATION</p><p>PSYCHIATRIST/LAST TREATMENT FACILITY: ______DATE LAST TREATED: ______</p><p>STREET ADDRESS: ______CITY: ______STATE: _____ ZIP CODE: ______</p><p>PHONE: ______FAX: ______</p><p>MEDICAL INFORMATION</p><p>DIAGNOSIS:</p><p>DAYTIME MEDICATIONS:</p><p>NIGHTTIME MEDICATIONS:</p><p>PRIOR ADVERSE MEDICATION EFFECTS (i.e. side effects, allergies, poor efficacy): ______</p><p>______</p><p>IS SUICIDE A CONCERN? NO ______YES ______IF YES, WHY? ______</p><p>OTHER MEDICAL CONCERNS: ______</p><p>MEDICAL DOCTOR’S NAME: ______OFFICE PHONE: ______</p><p>STREET ADDRESS: ______CITY: ______STATE: _____ ZIP CODE: ______</p><p>JAIL PSYCHIATRIC SERVICES (JPS)</p><p>EITHER CALL THIS INFORMATION IN TO JPS AT (916) 874-5222 OR FAX THIS FORM TO 916-874-8143</p>