Reception Order signed by: P. M. Martineau, Dated: January 19, 1894
Sex and Age: m 60
Civil State: Married
Occupation: Printer
Religion: Ch. of Eng.
First Attack: Yes
Age on first attack: 60
When and where previously under treatment: Claybury Asylum (Crossed out)
Duration of present attack: 1 week
Supposed cause: Unknown
Epileptic: No
Suicidal: No
Dangerous to others and how: No
Any near relative afflicted with Insanity: Not Known
Union chargeable to: St. George's E.
Previous Place of Abode: 5 Richard St., St. george's E.
Name and Address of Person to whom Notice of Death to be sent: Nil
Names and Addresses of one or more relatives of the Patient: Harriett McLean, 61 Bromehead St., Commercial Rd. E.
Medical Certificate Signed by: Toogood
Facts indicating insanity observed by myself at the time of examination viz.:
He talks to imaginary persons. He continually tries to grasp imaginary articles. He shouts without apparent cause.
Facts communicated by others viz.:
Transferred from: Claybury
Mental State:-
As far as possible under such Headings as:
Attention, Comprehension and Re-action, Cognition of self and surroundings, including mistakes of identity and appreciation of time and place, States of Stupor and Catalepsy, Memory for recent and remote events, Association and flow of ideas, Coherence, Reasoning power, Hallucinations, Illusions, Delusions, Exaltation, Fantasies of dress, Excitement, Depression, Impulses—General, Suicidal, Homicidal, Erotic, Destructive, Obsessions, Resistiveness or Hostility, Restlessness, Self-employment, Attention to personal needs, Religiosity, Sense of propriety, Lewdness of conversation and conduct, Regard for relatives.