| 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 | __________________ | |
| Signed (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.
| Name, with Christian | |
| Name at length | ____________________________________ |
| Rank, Profession or | |
| Occupation (if any) | ____________________________________ |
| How related to, or | |
| otherwise connected | |
| with the Patient | ____________________________________ |
(a) Insert residence of patient.
(b) County, city, or borough, as the case may be.
(c) Insert profession or occupation, if any.
(d) Insert the place of examination, giving the name of the street, with number or name of house, or should there be no number, the Christian and surname of occupier.
(e) County, city, or borough, as the case may be.