Arkham Sanitarium Intake Form — Printable Prop

Click any dotted line and type · then print

Ward C

Arkham Sanitarium

Arkham, Massachusetts · Record of Admission · Form S-11

Name of patient

Date of admission

Age

Occupation

Residence

Brought by

Committal

Presenting condition on admission

Statements made by the patient — record verbatim

Effects surrendered at the desk

Disposition

Attending physician

Form S-11 · in triplicate · the desk keeps the pink copy Arkham Inmate · est. 2010