| Reception Order for Tom Rampton |
| Name of patient and Christian name at length |
Tom Rampton
| 8470 |
| Sex and age |
M |
26 |
| Married Single or widowed |
S |
| Condition of life and previous occupation |
Labourer |
| Religious persuasion as far as known |
Church of England |
| Previous place of abode |
Fareham Union Workhouse. |
| Whether first attack |
Yes |
| Age (if known on first attack) |
25 years |
| When and where previously under treatment |
None |
| Duration of existing attack |
About 12 months |
| Supposed cause |
Unknown |
| Supposed cause |
No |
| Whether subject to epilepsy |
No |
| Whether suicidal |
Doubtful |
| Whether dangerous to others |
No |
| Whether any near relative has been afflicted with insanity |
No |
| Parish or union to which lunatic is chargeable (if a
pauper or destitute lunatic) |
Fareham Union |
| Name and Christian name and place of abode of the nearest known relative of the patient and degree of relationship if known |
James Rampton, Father, living at no 12 South Wallington, Fareham |
| Signed |
John Bennett, Relieving Officer of the Fareham Union |
| Medical certificate |
| Examined on |
25th January 1899 |
| Examined at |
The union house, Fareham |
| Facts indicating insanity observed by myself
|
Is of a most taciturn disposition with a fatuous expression. Questioned as to his absconding with the Workhouse clothing says he thinks it is quite the right thing to do when he wishes to leave the House to walk out when nobody is looking. |
| Other facts(if any) indicating Insanity communicated to me by others |
Mr Thomas Trott(?) Master of the Fareham Union House informs me that Tom Rampton is continually wandering off from the House without leave. He is restless at night. |
| Certifying doctor |
Illegible |
