Rule 12.36—Form 4: Physician or Mental Health Professional’s Report of Examination Completed Form Examples and Samples
Explore practical examples and samples of Rule 12.36—Form 4: Physician or Mental Health Professional’s Report of Examination. Learn how to accurately complete this Iowa legal form with our detailed, annotated templates.
Automated Processing of Rule 12.36—Form 4: Physician or Mental Health Professional’s Report of Examination
How this form was filled:
This example demonstrates how an AI model can parse complex, narrative clinical notes to populate the Iowa Rule 12.36—Form 4. By extracting data from unstructured psychiatrist dictation, the system accurately maps clinical observations, patient demographics, and professional details directly into the required legal form structure.
Source document used: Physician Clinical Dictation Notes
Dictation notes for Dr. Elena Vance regarding patient John Arthur Smith (DOB: 05/12/1982), residing at 452 Oak Street, Des Moines, IA 50309. The examination for case number EQCV098432 occurred on February 14, 2026, at 10:30 a.m. in Polk County. During the interview, Mr. Smith appeared disheveled and exhibited signs of paranoid delusions regarding his neighbors. He is currently employed as a freelance software developer, is single, and has no children. His mother, Mary Smith, living at 122 Maple Lane, Ames, IA 50010, is his nearest relative. The examination was conducted with the assistance of Sarah Jenkins, a licensed clinical social worker with Mercy Behavioral Health located at 411 Laurel Dr, Des Moines, IA 50314. In my medical judgment, the respondent is suffering from severe mental illness. He demonstrates a lack of capacity for responsible decision-making regarding his immediate hospitalization, as evidenced by his refusal to eat, citing fears of poisoning. He was not under the influence of medication at the time of the exam. I strongly recommend inpatient stabilization given his recent history of self-neglect and physical decline. I have reviewed the requirements under Iowa Code 229.10 and verify this report as the attending physician.
Information used to fill out the document:
- Patient Identity: John Arthur Smith, DOB: 05/12/1982, Male
- Case Details: Case EQCV098432, Polk County, Feb 14, 2026
- Clinical Staff: Dr. Elena Vance (Physician), Sarah Jenkins (LCSW)
- Facility: Mercy Behavioral Health, Des Moines, IA
- Diagnosis/Risk: Severe mental illness, lacks decision-making capacity, no medications administered
- Relative: Mary Smith (Mother), Ames, IA
What this filled form sample shows:
- Intelligent extraction of temporal data (a.m./p.m. conversion)
- Mapping of unstructured prose to specific checkbox fields
- Relational data parsing (identifying patient vs. assisting professional)
- Standardization of addresses and contact details
Form specifications and details:
| Form Title: | Rule 12.36—Form 4: Physician or Mental Health Professional’s Report of Examination |
| Jurisdiction: | Iowa Judicial Branch |
| Target Use Case: | Emergency mental health hospitalization assessment |
| Compliance Standard: | Iowa Code 229.10 |
| Categories: | health forms, mental health forms, physician forms |
| Created: | May 25, 2026 11:36 PM |