Interstate Corrections Compact Transfer Medical Summary Form

IDAHO DEPARTMENT OF CORRECTIONS

Use the ‘Tab’ or ‘arrow’ keys to navigate from one field to the next.
From Sending State:

To Receiving State:

Offender Name (Last, First, M):
Aliases/Maiden Name:

Social Security Number:
SID Number:
Date of Birth:

Allergies:

None
Dietary Restrictions:

None
Medical History (past and current):

None
Surgical History:

None
Psychiatric History: (DSM III-R Diagnoses and Psych, hospital admissions)

None
Alcohol/Drug Use: (type and duration of use if known)

None
Current Medications:

None
Medication
Dose
Route
Frequency

Test/Immunization History (attach copies of abnormal test results)
Test
Date
Result
Test
Date
Result
PPD

RPR

CXR

CBC

DIP/TET

MMR

DNA

Other:      

Dental
Is offender undergoing treatment currently?
Yes < No
Prepared by:
Work Telephone:
Date:

(     )      

Health Authority’s Signature Approval:
(For mental health issues, consult with the chief psychologist.)
Work Telephone:
Date:
( </w:t></)
IDAHO DEPARTMENT OF CORRECTION
Interstate Corrections Compact Transfer Medical Summary Form
Appendix APage 2 of 2
313.02.01.001
(Appendix last updated 6/6/12)