=Dated= this _______________ day of __________ 19____ STATEMENT OF PARTICULARS REFERRED TO IN THE ANNEXED ORDER _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 } __________________________ =Signed= _________________________________________ 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 ______________________________