Questionnaire

Victim of Nazi euthanasia - nonconformist activist and author. Murdered January 26, 1944.

Here is a translation of the questionnaire Nazi doctors used to determine whether or not a patient was fit to live (found on USHMM site).

T4 (code name referring to the gas chamber) MEDICAL QUESTIONNAIRE

Questionnaire 1  

Case no..............................................................

Name of Institution:.............................in:..................

First and family name of patient:................maiden name:.........

Date of birth:.............City:......................District:.......

Last Residence:.......................................District:.......

Unmarr., marr., wid., div.:.....Relig:.....Race(a)......Natlty:.........

Address of nearest relative:..........................................

Regular visits and by whom (address):.................................

Guardian or Care-Giver (name, address):...............................

Cost-bearer:...................How long in this inst.:................

In other Institutions; when and how long:.............................

How long sick:...........From where and when transferred:.............

Twin yes/no..............Mentally ill blood relatives:................

Diagnosis:............................................................

Primary symptoms:.....................................................

Mainly bedridden? yes/no....Very restless yes/no....Confined yes/no....

Incurable phys. illness: yes/no:.......War casualty: yes/no............

For schizophrenia: Recent case......Final stage.....good remission.....

For retardation: Debility:..........Imbecile:.......Idiot:.............

For epilepsy: Psych. changes........Average freq. of attacks...........

For senile disorders: Very confused..................Soils self........

Therapy (Insulin, Cardiazol, Malaria, Salvarsan, etc.): Lasting effects: yes/no....

Referred on the basis of §51, §42b Crim. Code, etc.........By..........

Crime:............Earlier criminal acts:....................

Type of Occupation: (Most exact description of work and productivity, e.g. Fieldwork, does not do much.--Locksmith's shop, good skilled worker.--No vague answers, such as housework, rather precise: cleaning room; etc.. Always indicate also, whether constantly, frequently or only occasionally occupied).............................................................

Release expected soon.................................................

Remarks:..............................................................

Do not mark in this Space.

..................................... Place, Date...................

..................................... ..................................... ...............................

(Signature of medical director or his

representative)

(a)German or related blood (German-blooded), Jew, Jewish Mischling (half-breed) 1st or 2nd degree, Negro (Mischling), Gypsy (Mischling), etc.

Translated in Robert J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York, 1986), pp. 68-69.

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