The word Lunatic, as used in this Act, shall mean and include every person of unsound mind, and every person being an idiot
Magistrate . The word Magistrate shall include a person exercising the powers of a Magistrate.
SCHEDULE
FORM A.
Certificate of Medical Officer. (See Sections IV and VIII).
I, the undersigned, (here enter name and official designation,) hereby certify that I, on the day of at, personally examined (here enter name and residence of Lunatic) and that, the said is a Lunatic (or an idiot, or a person of unsound mind) and a proper person to be taken charge of, and detained under care and treatment, and that I have formed this opinion on the following grounds, namely:
1. Facts indicating insanity observed by my self (here state the facts.)
2. Other facts (if any) indicating insanity communicated to me by others (here state the information and from whom.)
(Signed)
FORM B.
Order for the reception of a private patient. (See Section VII).
I, the undersigned, hereby request you to receive A.B., a Lunatic, [or an idiot, or a person of unsound mind] as a patient into your Asylum. Subjoined is a statement respecting the said A.B.
(Signed) name
Occupation (if any)
Place of abode
Degree of relationship (if any), or other circumstance of connexion with the patient.
Dated this day of one thousand eight hundred and
To Superintendent of the Asylum at [describing the Asylum].
STATEMENT.
[If any of the particulars in this Statement he not known, the fact to be so stated.]
Name of patient, with Christian name at length.
Sex and age.
Married, single, or widowed.
Condition of life, and previous occupation (if any).
The religious persuasion, as far as known.
Previous place of abode.
Whether first attack.
Age (if known) on first attack.
When and where previously under care and treatment.
Duration of existing attack.
Supposed cause.
Whether subject to Epilepsy.
Whether suicidal.
Whether dangerous to others.
Whether found Lunatic by inquisition or enquiry under order of Court, and date of Commission or order for inquisition or enquiry.
Whether any member of patient's family has been or is affected with insanity, (Signed) Name.
[Where the person signing the Statement is not the person who signs the order, the following particulars concerning the person signing the Statement are to be added; namely,]
Occupation (if any).
Place of abode.
Degree of relationship (if any), or other circumstances of connexion with the patient.