16 November 1939

The Reich Minister of the Interior

Berlin, NW 40, Koenigsplatz 6,16 November 1939

IV g 4178 /39-5100

Telephone: Dept. Z, I,11,V, VIII 1100 27
Dept. 11,IV, VI (Unter den Linden 72) ;12 00 34
Tel. Address : Reichsinnenminister

To the Head of the Hospital for Mental Cases
Kaufbeuren
or his deputy in Kaufbeuren.

With regard to the necessity for a systemized economic plan for hospitals and nursing institutions, I request you to complete the attached registration forms immediately in accordance with the attached instruction leaflet and to return them to me. If you yourself are not a doctor, the registration forms for the individual patients are to be completed by the supervising doctor. The completion of the questionnaires is, if possible, to be done on a typewriter. In the column "Diagnosis" I request a statement as exact as possible, as well as a short description of the condition, if feasible.

In order to expedite the work, the registration forms for the individual patients can be dispatched here in several parts. The last consignment, however, must arrive in any case at this Ministry at the latest by 1 January 1940. I reserve for myself the right, should occasion arise, to institute further official inquiries on the spot through my representative.

per proxi: DR. CONTI

Certified :
(Sd.) [Illegible]
Administrative Secretary.

To be Typewritten

Registration Form 1

Current No_________
Name of the Institution_________________________________________________
At:_______________________________________________________________
Surname and Christian name of the patient:___________________________________
At birth____________________________________________________________
Date of birth:_______________Place:___________________District:_____________
Last place of residence:_______________________________District:_____________
Unmarried, married, widow, widower, divorced:_________________________________
Religion:____________________________Race*:___________________________
Previous profession:_________________________Nationality:___________________
Army service when? 1914–1918 or from 1–9–39_________________________________
War injury (even if no connection with mental disorder) Yes/No______________________
How does war injury show itself and of what does it consist?_________________________
__________________________________________________________________
Address of next of kin:___________________________________________________
Regular visits and by whom (address):________________________________________
Guardian or nurse (name,address):__________________________________________
Responsible for payment:_________________________________________________
Since when in Institution:_________________________________________________
Whence and when handed over:_____________________________________________
Since when ill:_________________________________________________________
If has been in other institutions, where and how long:______________________________
Twin? Yes/No:__________Blood Relations of unsound mind:_______________________
Diagnosis:____________________________________________________________
Clinical description (previous history, course, condition; in any case ample data regarding
mental condition________________________________________________________
____________________________________________________________________
Very restless? Yes/No____________________Bedridden? Yes/No___________________
Incurable physical illness: Yes/No (which)_______________________________________
Schizophrenia: Fresh Attack__________Final Condition_________Good Recovery_________
Mental debility: Weak_______________Imbecile______________Idiot_______________
Epilepsy: Psychological alteration_____________Average frequency of the attacks__________
Therapeutics (insulin, cadiazol, malaria, permanent result:_____________________________
Salvarsan, etc. when?)_________________________________________Yes/No________
Admitted by reason par. 51. par. 42b German Penal Code, etc. through_____________________
______________________________________________________________________
Crime:___________________Former punishable offenses:___________________________
Manner of employment (detailed description of work):_________________________________
Permanent /Temporary employment, independent worker? Yes/No________________________
Value of work (if possible compared with average performance of healthy person)_______________
This space to be left blank.

___________________Place, Date__________________
____________________________________________
Signature of the head doctor or his representative (doctors who
are not phychiatrist or neurologists, please state name)

*German or of similar blood (of German blood), Jew, Jewish mixed breed Grades I or II, Negro (mixed breed)