Texas > Local County > Travis > Probate
Physicians Certificate Of Medical Examination - Texas
| Physicians Certificate Of Medical Examination Form. This is a Texas form and can be used in Probate Travis Local County . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
PHYSICIAN'S CERTIFICATE OF MEDICAL EXAMINATION In the Matter of the Guardianship of _____________________________________, an Alleged Incapacitated Person For Court Use Only Court Assigned:__________________ Revision June 1, 2012 The purpose of this certificate is to enable the Court to determine whether the individual identified above is incapacitated according to the legal definition, and whether a guardian should be appointed to care for him or her. LEGAL DEFINITION OF INCAPACITY For purposes of this certificate, an "Incapacitated Person" is "an adult individual who, because of a physical or mental condition, is substantially unable to provide food, clothing or shelter for himself or herself, to care for the individual's own physical health, or to manage the individual's own financial affairs." Texas Probate Code ยง 601(14). GENERAL INFORMATION Proposed Ward's Name ________________________________________________________________________ Date of Birth _________________________________ Age___________ Gender M F Current Location of Ward: ______________________________________________________________________ Physician's Name _______________________________________________ Phone: (______)______________ Office Address _______________________________________________________________________ _______________________________________________________________________ NO -- I am a physician currently licensed to practice in the State of Texas. I have been the doctor for the Proposed Ward since _______________________________ I last examined the Proposed Ward on _______________________, 20______ at: a Medical facility the Proposed Ward's residence Other: _________________________________________________________________ YES NO -- The Proposed Ward is under my continuing treatment. YES NO -- Prior to the examination, I informed the Proposed Ward that communications with me would not be privileged. YES NO -- A mini-mental status exam was given. If "YES," please attach a copy. ============================================================================================= Based upon my last examination of the Proposed Ward, I provide the following information: 1. EVALUATION OF THE PROPOSED WARD'S PHYSICAL CONDITION Physical Diagnosis: __________________________________________________________________________ Conditions underlying diagnosis: ______________________________________________________________ a. Prognosis: ________________________________________________________________ b. Severity: Mild Moderate Severe c. Treatment: ________________________________________________________________ 2. EVALUATION OF THE PROPOSED WARD'S MENTAL FUNCTION Mental Diagnosis: ___________________________________________________________________________ Conditions underlying diagnosis: ______________________________________________________________ a. Prognosis: ________________________________________________________________ b. Severity: Mild Moderate Severe c. Treatment: ________________________________________________________________ YES NO --- A summary of Proposed Ward's medical history is attached (if reasonably available). YES NO --- Would the Proposed Ward benefit from supports and services that would allow the individual to live in the least restrictive setting? YES NO --- Does this mental diagnosis include dementia? PAGE 1 OF 4 American LegalNet, Inc. www.FormsWorkFlow.com YES PHYSICIAN'S CERTIFICATE OF MEDICAL EXAMINATION Revision June 1, 2012 2. EVALUATION OF THE PROPOSED WARD'S MENTAL FUNCTION, continued YES NO --- Would the Proposed Ward benefit from placement in a secured facility for the elderly or a secured nursing facility that specializes in the care and treatment of people with dementia? YES NO --- Would the Proposed Ward benefit from medications appropriate for the care and treatment of dementia? YES NO --- Does the Proposed Ward have sufficient capacity to give informed consent to the administration of dementia medications? 3. DECISION MAKING Alertness, Attention, and Deficits Alertness: Alert Lethargic Stupor Proposed Ward is oriented to the following (check all that apply): Person Time Place Situation In my opinion, the ability of the Proposed Ward to make or communicate responsible decisions concerning himself or herself is affected by the Proposed Ward's deficits and abilities as indicated: Deficit(s) (check all that apply): Short-term memory YES YES YES YES YES Long-term memory Immediate recall YES YES NO --- Able to understand or communicate (verbally or otherwise) NO --- Able to recognize familiar objects and persons NO --- Able to perform simple calculations NO --- Able to reason logically NO --- Able to grasp abstract aspects of his or her situation or to interpret idiomatic expressions or proverbs NO --- Able to break complex tasks down into simple steps and carry them out NO --- The Proposed Ward's periods of impairment from the deficits indicated above (if any) vary substantially in frequency, severity, or duration In my opinion, the Proposed Ward is able to make or communicate responsible decisions concerning himself or herself regarding the following: A. Business and Managerial Matters; Financial Matters YES NO --- Contract and incur obligations; handle a bank account; apply for, consent to and receive governmental benefits and services; accept employment; hire employees; sue and defend on lawsuits; make gifts of real or personal property? YES NO --- If "YES," should amount deposited in any such bank account be limited? YES NO --- Execute a Durable Power of Attorney? YES NO --- Execute a Health Care Power of Attorney? B. Personal Living Decisions YES NO --- Determine own residence? YES NO --- Safely operate a motor vehicle? YES NO --- Vote in a public election? YES NO --- Make decisions regarding marriage? C. Medical Decision-Making YES NO --- Consent to medical, dental, psychological, and psychiatric treatment? YES NO --- Administer own medications on a daily basis? D. Daily Life Activities Administer daily life activities (e.g., bathing, grooming, dressing, walking, toileting): YES, independently YES, with assistance NO, requires total care PAGE 2 OF 4 American LegalNet, Inc. www.FormsWorkFlow.com PHYSICIAN'S CERTIFICATE OF MEDICAL EXAMINATION 4. DEVELOPMENTAL DISABILITY YES NO --- Does the Proposed Ward have developmental disability? Revision June 1, 2012 If "NO," skip to number 5 on the next page. If "YES," is the disability a result of the following? (Check all that apply) YE
|
|||||||
