1881 public laws – Ch.206 Sec.16

Source: model

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Whenever the justices of the peace, under the provisions of the preceding section, shall direct any insane person to be removed to the asylum as a patient for safekeeping, it shall be their duty to make a full report of their proceedings to the clerk of the superior court of their county. The following interrogatories with their respective answers by competent witnesses shall likewise be transmitted with the other papers to the board of directors: Question 1 What is the name of the patient? Question 2 Is he or she white or colored ? Question 3 What is his or her age? Question 4 Is he or she married or single ? Question 5 What is the supposed cause of insanity ? Question 6 In what way is the disease exhibited ? Question 7 Has any medical treatment been pursued ? If so, what kind, and by whom? Question 8 How long has he or she been insane? Count from first symptoms. Question 9 Has the patient manifested any propensity to injure himself or others? If so, in what way ? Question 10, Has he or she been subject to epilepsy ? Question 11 Has any of his or her ancestors been insane? If so, state what ancestors, and what was the character of their insanity ? Question 12 Has he orshe any family, and, if so, what persons compose it? 26 Question 13 Are any of them insane, and what is the character of such insanity ? Question 14 What is the occupation of the patient ? Question 15 How many attacks of mental disease has the patient had? Question 16 Are the parents of the insane person related by blood? If so, what is the degree of relationship ? Question 17 Has the applicant property? If so, state in what such property consists, and what is the value thereof? Question 18 Is the applicant under any forcible restraint? If so, what? Question 19 Has the patient received any aid from the county? If so, what? Question 20 Give name and address of the friends of the patient, with whom the superintendent can regularly correspond in his behalf.

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