Reception Order signed by: John Rose, Dated: June 7, 1893
Sex and Age: m 18
Civil State: Single
Occupation: None
Religion: Protestant
First Attack: Yes
Age on first attack: 18
When and where previously under treatment: Claybury Asylum (Crossed out)
Duration of present attack: 3 days
Supposed cause: Falling & striking his head
Epileptic: Yes
Suicidal: No
Dangerous to others and how: At times
Any near relative afflicted with Insanity: No
Union chargeable to: Whitechapel
Previous Place of Abode: 65 Felton St., Hoxton
Name and Address of Person to whom Notice of Death to be sent: Mrs. Nicholls (Mother) 42 Phillip St., Hoxton
Names and Addresses of one or more relatives of the Patient: Mrs Harding, 15 Shap St., Kingsland Rd., N.E.
Medical Certificate Signed by: Leonard
Facts indicating insanity observed by myself at the time of examination viz.:
He is excitable & violent & would do harm to others unless prevented. He is subject to fits of an apoplectic character.
Facts communicated by others viz.:
Charles Judd, the Attendant states that he is very violent & tried to injure the other patients.
Transferred from: Claybury Asylum
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.