27A-11A-8. Interrogatories to be answered with health professional's certificate or examination. If a hearing is held on a petition for involuntary commitment, correct answers to the following interrogatories, so far as they can be obtained, shall accompany the report of the qualified mental health professional's initial examination, which shall be provided to the person's attorney and state's attorney prior to the hearing:

(1) HISTORY

(a) Informant: (1) Name

(2) Address

(3) Relationship

(b) Patient: (1) Full name

(2) Born, place, date

(3) Sex, race, education

(4) Occupation

(5) Social Security No.

(6) How long in South Dakota

(7) Marital status

(c) Wife/Husband: (1) Name

(2) Address

(d) Father: (1) Full name

(If a minor) (2) Address

(e) Mother: (1) Full name

(If a minor) (2) Address

(f) Next of kin: (1) Full name

(2) Address

(3) Relationship

(g) Legally responsible relative or guardian:

(1) Full name

(2) Address

(3) Relationship (h) Military service (i) Previous treatment for mental illness: Give dates and places of treatment, dates of previous hospitalization, etc. (j) A review of previous behavior or acts which led to involuntary commitment or treatment which are similar or related to the person's present psychiatric condition or status (2) EXAMINATION Findings: (a) Physical condition, including any special test results: (b) Present mental condition: (c) Is this patient considered to be a danger to himself? If so, explain: (d) Is this patient considered to be a danger to others? If so, explain: (e) Diagnostic impression: (f) Is the person taking any medication or drugs? List them if known. In your opinion, do these have an effect on the person's current behaviors? If so, explain: (g) In your opinion, could this person benefit from treatment? If so, please list the least restrictive alternatives: (h) Signature of qualified mental health professional.