Describe three items that are documented on a health summary transfer form.

Any three of the following:
transfer date

name, address, and phone number of the transferring facility and receiving facility

inmate's name, identification number, date of birth

date of last physical

known allergies

date of last tuberculin test and results

behavioral or mental health conditions, suicide attempt, or gesture during current or prior incarceration

medical conditions

current medications, including medication name, dose, frequency

restrictions (if any) on activities, diet, housing, other

adaptive devices

HIV status

Current dental problems

Follow-up appointments

Signature of individual preparing the health summary transfer form and the signature of the person receiving the health transfer information.

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