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  • Docthan Suckhoe

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    This document is a pre-marital mental health examination form containing 4 parts. Part 1 requests the doctor's information. Part 2 requests the applicant's information. Part 3 will contain the results of the examination, stating whether the applicant does not have mental illness, has some problems but is conscious, or has a severe illness and lacks consciousness. Part 4 indicates any attachments such as a mental assessment should be included. The document needs to be signed and printed clearly by the examining doctor.

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    docthan-suckhoe

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    This document is a pre-marital mental health examination form containing 4 parts. Part 1 requests the doctor's information. Part 2 requests the applicant's information. Part 3 will contain the results of the examination, stating whether the applicant does not have mental illness, has some problems but is conscious, or has a severe illness and lacks consciousness. Part 4 indicates any attachments such as a mental assessment should be included. The document needs to be signed and printed clearly by the examining doctor.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    12 views1 page

    Docthan Suckhoe

    Uploaded by

    tqngoc212
    This document is a pre-marital mental health examination form containing 4 parts. Part 1 requests the doctor's information. Part 2 requests the applicant's information. Part 3 will contain the results of the examination, stating whether the applicant does not have mental illness, has some problems but is conscious, or has a severe illness and lacks consciousness. Part 4 indicates any attachments such as a mental assessment should be included. The document needs to be signed and printed clearly by the examining doctor.

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    of 1

    PRE-MARITAL EXAMINATION OF MENTAL HEALTH

    Kt qu Khm Sc khe Tm thn Tin Hn nhn

    Part/Phn I: Doctors Information/Bc s Full Name:


    H v tn:

    . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    License Number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Giy php hnh ngh s: Name of Institution: . . . . . . . . . . . . . . . . . . . . . . . . . . .


    Tn Phng khm/Bnh vin:

    Address and Tel:


    a ch v in thoi

    . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part/Phn II: Applicants Information/ng n

    Full Name:
    H v tn:

    Mr.
    ng

    Ms.
    C

    . . . . . . . . . . . . . . . . . . . . . . . .

    Date of Birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
    Ngy sinh: dd mm yyyy

    Address:

    . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part/Phn III: Results/Kt lun:

    a ch v in thoi:

    Currently,
    Hin ti,

    Mr.
    ng

    Ms.
    C

    . . . . . . . . . . . . . . . . . . . . . . . .

    Does NOT suffer from mental illnesses.


    Khng mc bnh tm thn.

    Has mental problems, but NOT to the extent of losing consciousness of his/her actions;
    Mc bnh tm thn, nhng cha n mc khng c kh nng nhn thc c hnh vi ca mnh;

    Has a mental illness and is not capable of being conscious of his/her actions.
    Mc bnh tm thn, khng c kh nng nhn thc c hnh vi ca mnh.

    Part/Phn IV: Attachments/nh km Mental Assessment


    Ngy khm:

    Others/Khc

    . . . . . . . . . .

    Date of Examination: . . . . . . . . . . . . Signature of Doctor: . . . . . . . . . . . .


    Bc s k tn:

    Full Name in Print: . . . . . . . . . . . . .


    Ghi y h tn:

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