This is from the 1974 chronicle and is not intended to reflect in any way on the current state of the National Health Service!

Code URI/NAL BED/PAN

APPLICATION FOR PERMIT TO BE ILL

NATIONAL HEALTH SERVICE

NAME ........................................National Insurance No ..............

ADDRESS ........................................................................................

When Born and Why? .........................................

1. I hereby make an application to be ill. (Permit)

2. I hereby declare that :-

(a) I have a pain in my (i)head....(ii)stomach....(iii)chest....(iv)arms....(v)orifice.......(vi)other(please specify)........
(b) my complexion is (i)ruddy....(ii)pallid....(iii)green....
(c) I have broken my (i)arm....(ii)leg....(iii)back....(iv)engagement....
(d) During the past 12 hours I have been sick....times
(e) I expect to be sick again in....hours
(f) I am afraid I shall (i)die....(ii)not die....(iii)live....(iv)not live....
(g) I am off my (i)food....(ii)drink....(iii)head....

3. The name of my Doctor/Veterinary Surgeon is .......................

4. I have been taking
(i)salts....(ii)pills....(iii)tablets....(iv)liberties....

5. I am in
(i)bed....(ii)pain....(iii)desperation....(iv)my coffin....

6. I can see
(i)spots....(ii)nothing....(iii)animals....
(If animals, state type and colour.)

7. I have spots on my ................
(a)They do/do not itch....(b)I am/am not scratching them....

8. I am/am not pregnant....
(In the case of male patients, please provide further details on a separate sheet. Blankets cannot be accepted.)

9. I am
(i)depressed....(ii)elated....(iii)about to shoot myself....
(Note: In the last case , a current Firearms Licence must be held.)

10. I would be willing to take
(i)medicine....(ii)treatment....(iii)medicine/treatment....(iv)poison....
(Please clearly state preference and whether fast or slow)

11. I request admission to
(i)a hospital....(ii)an asylum....(iii)the mortuary....

12. I request the services of a
(i)doctor....(ii)midwife....(iii)nurse....(iv)undertaker....
(If nurse required, please state whether day, night, wet, dry, blonde, brunette, young or old)

If a permit cannot be issued for your complaint, would you be prepared to accept another illness, malady or disease? State YES or NO...........

When completed, this form must be submitted, in triplicate, to the Local Health Officer. Should the applicant die before the permit is issued, the Local Health Officer must be notified, and a new application for a permit to be declared dead (Form R.I.P.) must be submitted by any surviving relative or creditor.

Signature........................................................Date.........................