No.i.] PSYCHOLOGICAL EXAMINING IN THE UNITED STATES ARMY. 291 



PSYCHOLOGICAL REPORT FORM 



(1) All cases of mental deficiency recommended for discharge. 



(2) All cases for which neuro-psychiatric examination is especially indicated. 



[Report to be made in duplicate; one copy for division surgeon; one for S. G. 0., Division of Psychology; forwarded 

 weekly.] ■ 



Date 191 .. . Camp 



Name Company 



Regiment Arm 



Born in Years in United States 



1. Family history 



Personal disease history 



2. Social status 



3. Occupation Weekly wages $ Jobs in past year 



4. Education: Grade reached Age left school Write letters? Read newspapers? 



5. General information: President? Own State? 



County? Make change? 10-6? 25-8? 50-14? 



2 for 5, how many 50? Know general orders? Names of own 



officers? Current events? 



Judgment 



6. Orientation : Place? Date? 



Name days of week? 



Months 



Sun rises? Sets? Directions?. 



7. Affective state Troubles? 



Sex habits 



8. Language and speech : English Defects. 



9. Company record 



10. Alpha Beta Mental age Scale. 



Peculiarities in test Skill test 



REMARKS AND RECOMMENDATIONS. 



Examiner. 



