13 9/23/75 name : glick , daniel francis address : rfd # i , brock road , jerusalem 's lot , maine 04270 age : 12 sex : male race : caucasian admitted : 9/22/75 admitting person : anthony h. glick ( father ) symptoms : shock , loss of memory ( partial ) , nausea , disinterest in food , constipation , general loginess tests ( see attached sheet ) : 1 .