Verification
The statement contained or referred to in paragraphs are true to my knowledge; the other statements are true to my information and belief.
(Date)
EF
The statement of particulars above referred to The following is a statement of particulars relating to the said AB: Name of patient in full.— Sex and age.—
Married, single or widower.— Previous occupation.— Caste and religion.— Residence at the time of the application.—
Names of any near relative to the patient who are alive.—
Whether this is first attack of mental illness.—
Age on first attack.— Supposed cause.—
Whether the patient is subject to epilepsy.—
Whether suicidal.—
Whether the patient is known to be suffering from any form of tubercular 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, ganja, charas, bhang, cocaine or other intoxicant.—
(If any of the particulars in the above statement be not known, the fact to be
so stated).