Report (Medical)

IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT, LAKE COUNTY, ILLINOIS Probate Division Estate of ) ) ) ) No. An Alleged Disabled Person REPORT 1. The undersigned, being a physician licensed to practice medicine in all its branches in the State of Illinois, examined __________________________________, hereinafter called the Respondent, on ____________________________, 20 _______. 2. The following is an assessment, based upon my examination, of the Respondent's disability and how such disability impacts on the ability of the Respondent to make decisions or to function independently: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 3. The following is my evaluation of the Respondent's physical and educational condition, adaptive behavior and social skills: Mental condition: _______________________________________________________________ ____________________________________________________________________________________ Physical condition: ______________________________________________________________ ____________________________________________________________________________________ Educational condition: ___________________________________________________________ ____________________________________________________________________________________ Adaptive behavior: ______________________________________________________________ ____________________________________________________________________________________ Social skills: ___________________________________________________________________ ____________________________________________________________________________________ in self help skills. 171P-73 Rev. 09/00 Page 1 of 2 2002 © American LegalNet, Inc. 4. Based upon my examination and evaluation of the Respondent it is my opinion that: [] Guardianship is not needed. [] Guardianship is needed, and the type and scope of the guardianship needed and the reasons therefore are as follows: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 5. My recommendation as to the most appropriate treatment or habitational plan and living arrangement for the Respondent and the reasons therefore are as follows: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 6. The signatures of all persons who performed the evaluation upon which this report is based, one of whom shall be a licensed physician, as well as a statement of the certification, license or other credentials which qualify any evaluators. The evaluations were performed within 3 months of the filing of the petition: Preparer of Report: ____________________________________________________________________________________ Name Profession/Credentials Date of evaluation Performers of evaluations upon which this report is based: ____________________________________________________________________________________ Name Profession/Credentials Date of evaluation ____________________________________________________________________________________ Name Profession/Credentials Date of evaluation 171P-73 Rev. 09/00 Page 2 of 2 2002 © American LegalNet, Inc.