STATEMENT OF PARTICULARS REFERRED
TO IN THE ANNEXED PETITION

If any particulars are not known the fact is to be so stated.

[Where the patient is in the petition or order described
as an idiot, omit the particulars marked ►]

The following is a Statement of Particulars__________________
relating to the said__________________
Name of patient, with Christian name at__________________
length__________________
Sex and Age __________________
► Married, single, or widowed __________________
► Rank, profession, or previous occupation__________________
(if any)__________________
► Religious persuasion __________________
Residence at or immediately previous to__________________
the date hereof__________________
► Whether first attack __________________
Age on first attack __________________
When and where previously under care__________________
and treatment as a lunatic, idiot, or__________________
person of unsound mind__________________
► Duration of existing attack __________________
Supposed cause __________________
Whether subject to epilepsy __________________
Whether suicidal __________________
Whether dangerous to others, and in__________________
what way__________________
Whether any near relative has been__________________
afflicted with insanity__________________
Names, Christian names, and full postal__________________
addresses, of one or more relatives__________________
of the patient__________________
Name of the person to whom notice of__________________
death to be sent, and full postal__________________
address, if not already given__________________
‡Name and full Postal Address of the__________________
usual Medical Attendant of the Patient__________________
‡When the Certificate is not signed by the usual Medical Attendant,
 the Certificate on the other side must be filled out.

(a) When the
petitioner
or person
signing an
urgency order
is not the
person who
signs the
statement, add
the following
particulars
concerning
the person who
signs the
statement.

Signed (a)
Name, with Christian
Name at length____________________________________
Rank, Profession or
Occupation (if any)____________________________________
How related to, or
otherwise connected
with the Patient____________________________________

53 Vict. c. 5. s. 7 (4).

When a previous Petition has been dismissed.