3844 (Rev. 08/05) REPORT OF A PHYSICIAN STATE OF ILLINOIS UNITED STATES OF AMERICA COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT IN RE THE ESTATE OF CASE NUMBER Alleged Disabled Person File Stamp Here REPORT OF A PHYSICIAN medicine in all branches in the State of Illinois, submits the following report on alleged disabled person, based on an examination of the respondent on , a physician licensed to practice an . NOTE: The examination must have occurred no earlier than three months before the Petition for Guardianship is filed. 1. Describe the nature and type of the respondent's disability and provide an assessment of how the disability impacts on the ability of the respondent to make decisions or to function independently. (Please state underlying diagnosis, as well as manifestations of disability.) 2. Provide an analysis and results of evaluations of the respondent's mental and physical condition and, where appropriate, describe educational conditions, adaptive behavior, and social skills. 3. State whether, in your opinion, the respondent is TOTALLYor only PARTIALLYincapable of making PERSONAL and FINANCIAL decisions, and if the latter, the kinds of decisions which the respondent can and cannot make. Include the reasons for this opinion. 4. What, in your opinion, is the most appropriate living arrangement for the respondent, and if applicable, describe the most appropriate treatment or rehabilitation plan. Include the reasons for your opinion. Please indicate what restrictions are reasonably necessary to protect the assets and/or ensure the safety of the alleged disabled person. Signed (Print or type physician's name) License No. Address City/State/Zip *See page 2 on Reverse Telephone CHRIS KACHIROUBAS, CLERK OF THE 18TH JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60189-0707 American LegalNet, Inc. www.USCourtForms.com 3844(Rev. 08/05) REPORT OF A PHYSICIAN *This report must be signed by a physician. If the description of the respondent's mental, physical and educational condition, adaptive behavior or social skills is based on evaluations by other professionals, all professionals preparing evaluations must also sign the report. Evaluation on which the report is based must have been performed within 3 months of the date of the filing of the petition. 5. Provide a statement describing the certification, license or other credentials of the physician preparing this report. Names and signatures of other persons who performed evaluations upon which this report is based: Name Address Certification, licenses or other credentials Signature Name Address Certification, licenses or other credentials Signature Name: PRO SE DuPage Attorney Number: Attorney for: Address: City/State/Zip: Telephone: CHRIS KACHIROUBAS, CLERK OF THE 18TH JUDICIAL CIRCUIT COURT © American LegalNet, Inc. www.USCourtForms.com WHEATON, ILLINOIS 60189-0707