1899 public laws – Ch. 1 Sec. 19

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CHAPTER 1 An act to revise, consolidate and amend the insanity laws of this state. The General Assembly of North Carolina do enact: _

The following questions with their respective answers, by at least one. licensed physician, resident of this state, and such other competent witnessesas the clerk or justice shall determine, duly sworn and subscribed by them, and so certified by said clerk or justice, shall be transmitted with the other papers to the superintendent of the proper hospital, to be reported as soon as practicable to the board of directors. Pending the consideration of the ap tion by the board of directors, the patient shall remain in the custody of the officer or such person as the clerk may designate until it can be ascertained if there is room for the patient at the hospital. Questio& 1 What is the name of the patient? Answer ___.-.—.-Question 2 Is ……..-white or colored ? Amswer 2.2 J22:.–Question 3 . What is —.–.—-age? Answer __—.—–Question 4 What is the occupation of patient ? Answer ._.——–Question 5 Is ._._….__.married or single; and if married for how many years? Answer __..—–.-Question 6 If patient be married woman, state maiden name. Answer ___–_—–Question 7 Has ….-.–.–_any education, if so how much? Answer _..-.–.—Question 8 Where was __…_…–. born ? Answer 2222) 22-Feb Question 9 How many attacks of mental disease has the patient, had ? = Answers. 25s os Has) 2208) shoes been subject to epilepsy ? ( Q necting 12 How long has 22 .———been insane? (Count mm. the first symptoms of present attack, and give all known L aptoms from that time to this date.) > Question 13 In what way is the disease exhibited? i Answer ___–..—-f ) Question 1a as 8 2 any delusions? If so what are they? > Answer _._/____.—- Question 15 Is _-….-destructive to clothing or furniture? Answer ____-.—— i Question AGS) SIs e222 5220:00:00 filthy: or indecent ? – ‘ Answer Se ne eens Question 17 Has the patient manifested any propensity to injure = or others? If so, in what way and how often? Answer _.-._——Question 18 Has ..-……. ever threatened suicide ? Answer _._.___.__-. Question 19 Has ._…_.. ever attempted suicide? Answer ._-__-_–.– *Question 20 Has ___._.—- : ever threatened homicide? . Answer __…—.–Question 21 Has …..__.-. ever Maeboipted to commit homicide ? Answer _____…__-eet Question 22 Has __—–any family? And if so, what.persons compose it? Age of youngest child? _ Answer __.._-.-.–ea 23 Are any of thems insane, and what is the character 5 1 13 2 1 2 267 2036 103 34 95 such 5 1 13 2 1 3 383 2035 176 43 92 insanity 5 1 13 2 1 4 559 2028 27 40 92 ? 3 1 13 3 0 0 216 2049 473 89 -1 4 1 13 3 1 0 216 2049 473 89 -1 5 1 13 3 1 1 216 2049 201 89 0 Sitavior 5 1 13 3 1 2 437 2121 55 6 7 Lena 5 1 13 3 1 3 501 2122 12 4 10 ee 5 1 13 3 1 4 525 2121 55 5 4 aN 5 1 13 3 1 5 588 2121 101 5 7 CRA 3 1 13 4 0 0 206 2138 1465 111 -1 4 1 13 4 1 0 220 2138 1451 61 -1 5 1 13 4 1 1 220 2138 21 49 0 Question 24 Are parents of the insane person related by blood ? Tf so, what is the degree of case ? . Question 28 Has, any medical treatment, been pursued what kind and by whom ? ie Answer _……..–Bi Question 29 Is …..in jail? } Answer ……-.—- ye Question 30 Is -..–in poor house? Answer._..-.——- : i ee Question 31 Is _…-. under any forcible restraint ? If , Answer __…..-.-.- Question 32 Has patient any property? If so, eee a property consists, and what is the value thereof ? . Amswer _…_-..—so, what? Answer pga eS Sy with whom the Siperintadent of the ieee can conan circumstances require, for the benefit of the patient ? Answer __……—Relationship ._……..– : aie P. O. address …..-.1_-_aie ba .Question 35 Give any information in your possession not emi: braced in the above question, which may throw light on the mentai or physical condition of the patient? he Answer _…-..–.-. : a4 Same RN Rar ta ne by cid ected ,M.D am Vif STATE OF NORTH CAROLINA. Ma le 2c Nes ks aie County Wibinit Before ES im , Officer,. _.-22.2 een duly aitharived to : ad minister an oath, this …. day of -….., A..D….., came <..5..22 MDS ease one persons known to be credible and reliable. Se aeense sane person in their county, not admitted to the appropriate es a i: and not cammnitbed for crime, when it shall appear cppen thes ce Pa board, that such insane person ought to be discharged if in a hospital. '

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