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782                                               MEDICAL  JURISPRUDENCE

The following is the statement of particulars relating to the said A. B. : —

Name of the patient at length.

Sex and age.

Married or single or widowed.

Previous occupation.

Caste and religious belief, as far as known.

Residence at or immediately previous to the date hereof.

Names of any near relatives to the patient who are alive.

Whether this is a first attack of lunacy.

Age  (if known) on first attack.

When and where previously under care and treatment as a lunatic.

Duration of existing attack.

Supposed cause.

Whether the patient is subject to epilepsy.

Whether suicidal.

Whether the "patient is known to be suffering from phthisis or any form of tuber-
cular disease.

Whether dangerous to others, and in what' way.

Whether any near relative (stating the relationship) has been afflicted with insanity.

Whether the patient ' is addicted to alcohol or the use  of opium,  gunja,  charas,
bhang, cocaine or other intoxicant.

[The statements contained or referred to in paragraphs                      are true to my

knowledge.   The other statements are true to my information and belief/)

[Signature by person making the statement.]


(See sections 7, 10.)

I the undersigned E. F., being a Presidency Magistrate of

[or the District Magistrate of— or the Sub-Divisional Magistrate of—or a Magistrate of
the first class specially, empowered by the Government to perform the functions of a
Magistrate under Act IV of 1912] upon the petition of C. D. of1' in tho^maltcr o£ A. B,,?
a lunatic, accompanied by the medical certificates of G. H., a medical officer, and of J. K,,
a medical practitioner [or medical officer], under the said Act, hereto annexed, hereby
authorize you to receive , the said A. B. into your asylum. And I declare that I have '
(or have not) personally seen the said A. B., before making this order.

To [8]                                         >,                                                     (Sd,) E. F.

Designation as above,


(See sections 18, 19.)

In the matter of A. B. of0                              in the town of                         [or the

sub-division of                           in the district of                           ], an alleged lunatic.

1,  the undersigned C. D., do hereby certify as follows : —

I am a gazetted medical officer [or ;a medical .practitioner declared by government
I am a holder of10 [or declared by Local Government to be a medical practi-

to be medical officer under Act IV of 1912]

tioner under Act IV of 1912]                                                                   and I am in the

actual practice of the medical profession.

2.   On the                                          day of                  19            at ' 1 in the - !?wn

of [or the sub- division of         in the district of                     ] [separately from any other

practitioner],12 I personally examined the said A. B., and came to the conclusion that
the said A. B. is a lunatic and a proper person to be taken charge of and detained under
care and treatment.

3.   I formed this conclusion on the following grounds, viz. : — «

(a)  Facts indicating insanity observed by myself, viz. ; —

(b)  Other facts   (if any)   indicating insanity communicated  to me by  others,
viz. : —

Here state the information, and from whom.

(Sd.)  C. D.
Designation as above,

7.   Address and description,

, 8,   To be addressed to the officer or person in charge of the asylum.
9.   Insert residence of patient.

10.   Insert qualification to practise medicine  and surgery registrable  in  the  United
Kingdom.               '                                  !

11.  ''Insert place 'of examination.]    '1 ' '   ;    ' '  '

12.   Omit this where only one certificate is required.