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. [Sidenote: (_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=. [Sidenote: (_a_) Name of Patient. (_b_) Name of asylum, hospital, licensed house, or single charge. (_c_) Justice of the Peace for ———, or Judge of County Court of ——, or Stipendiary Magistrate for ———] I, the undersigned, hereby state that a former Petition for Reception of (_a_)___________________________________________ into (_b_)___________________________________________________ was presented to__________________________________________________ (_c_)________________________________________________________ in the month of________________ 19_______, and dismissed.