| Name | Residence when at home. City or town or township? | If now an inmate of an istitution is this person a pay patient. | Form of Disease. | Duration of present attack. | Total nmber of attacks. | Age at which first attack occurred. | Does this person require to be usually or often kept in a cell or other apartment under lock and key, either by day or at night? | Does this person require to be usually or often restrained by any mechanical appliance, such as a strap, strait-jacket, etc? If yes, state the character of the appliance used. | Has this person ever been an inmate of any hospital or asylum for the insane? If yes name the said hospital or asylum. | Is this person also an epileptic? | Is this person also suicidal? | Is this person also homicidal? |
