Page 1 of 4 FORM #539GC (01/2019) 62-5-303, 62-5-303D, 62-5-403, 62-5-403B, 62-5-403D, 62-5-304, 62-5-407, 62-5-407(B) STATE OF SOUTH CAROLINA ) ) COUNTY OF ) ) ) IN THE MATTER OF: ) PROBATE COURT USE ONLY , ) ) IN THE PROBATE COURT an alleged incapacitated individual. ) ) CASE NUMBER - GC - - ) ) EXAMINER REPORT AND AFFIDAVIT ) REGARDING CAPACITY ) Please answer the following questions concerning the alleged incapacitated individual (hereinafter, patient) and provide explanations or additional comments and details at the end of this form or on an attached sheet of paper. 1. : 2. Have you treated the patient previously ? If yes, how long? Yes No 3. a) Date(s) and place(s) of all examination(s) within previous ninety (90) days: b) Date(s) and place(s) of all examination(s) relied upon in making this report: 4. Please provide a diagnosis and assessment of the patient he/she is taking any medications that may affect his/her actions: Are additional tests or assessments, such as lab tests, neuroimaging/MRI, neuropsychological testing, or other tests needed in order to give a more definitive diagnosis? If so, what further tests or examinations are needed? 5. Please specify which diagnoses and/or condition(s) are progressive, permanent, or temporary. Progressive: Permanent: Temporary: 6. Please describe the nature and extent of any incapacity, including specific impairments: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 FORM #539GC (01/2019) 62-5-303, 62-5-303D, 62-5-403, 62-5-403B, 62-5-403D, 62-5-304, 62-5-407, 62-5-407(B) 7. Please describe the nature and extent of abilities, includin g those that would allow him/ her to accomplish 1 : 8. Does the patient have the capacity to retain the following rights (If you cannot attest to yes or no, please explain what additional test/s can be done to achieve that in form ation) : a) Marry or divorce ? Yes No Unknown b) Reside in a place of his/her choosing, and consent or withhold consent to any residential or custodial placement ? Yes No Unknown c) Travel without the consent of a guardian ? Yes No Unknown d) Give, withhold, or withdraw consent and make other in form ed decisions relative to medical, mental, and physical examinations, care, treatment , and therapies ? Yes No Unknown e) Make end - of - life decisions including, but not limited to, a order or the application of any medical procedures intended solely to sustain life, and consent or withhold consent to artificial nutrition and hydration ? Yes No Unknown f) Consent or refuse consent to hospitalization and discharge or transfer to a residential setting, group home, or other facility for additional care and treatment ? Yes No Unknown g) Authorize disclosures of confidential in form ation ? Yes No Unknown h) Operate a vehicle * ? Yes No Unknown i) Vote ? Yes No Unknown j) Be e mployed without the consent of a guardian ? Yes No Unknown k) Consent to or refuse educational services ? Yes No Unknown l) Participate in social, religious or political activities ? Yes No Unknown m) Buy, sell, or transfer real or personal property or transact business of any type ? Yes No Unknown n) Make, modify, or terminate contracts ? Yes No Unknown o) Bring or defend any action at law or equity ? Yes No Unknown p) Any other rights and powers? P lease list . COMPLETE EXPLANATION(S) FOR QUESTIONS a) through p) HERE. If more space is required, use additional sheets and attach . (* ducted. ) 1 As defined in S.C. Code Ann. 247 62-5- (a) systems in place for the alleged incapacitated individual to make decisions in advance or to have another person to act on his behalf, including, but not limited to, having an agent under a durable power of attorney, a health care power of attorney, a trustee under a trust, a representative payee to manage social security funds, a Declaration of Desire for Natural Death (living will), a designated health care decision maker under Section 44-66-30, or an educational representative designated under Section 59-33-310 to Section 59-33-370; and (b) reasonable accommodations that enable the alleged incapacitated individual to act as the principal decision maker, including, but not limited to, using technology and devices; receiving assistance with communication; having additional time and focused discussion to process information; providing tailored information oriented to the comprehension level of the alleged incapacitated individual; and accessing services from community organizations and governmental agencies. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 FORM #539GC (01/2019) 62-5-303, 62-5-303D, 62-5-403, 62-5-403B, 62-5-403D, 62-5-304, 62-5-407, 62-5-407(B) 9. Would the patient benefit from: a) Therapy or treatment ? b) Medical aids or equipment ? c) An operation or medical procedure(s) ? d) Psychiatric treatment ? Yes No Yes No Yes No Yes No 10. Has the patient had in the last six months: a) Hospitalization(s) ? b) Therapy or treatment ? c) Inpatient or outpatient surgery ? d) Major medical test(s) ? e) Psychological or psychiatric testing ? Yes No Yes No Yes No Yes No Yes No 11. In your opinion, does the patient have the ability to: a) effectively manage his/her property or individual financial affairs , provide for his/her support , or for the support of his/her legal dependents ? Yes No If yes , is the ability limited in any way? Please explain: b) meet the essential requirements for his/her physical health, safety, or self - care . Yes No If yes, is the ability limited in any way? Please explain: 12. The patient continues to per form the following activities of daily living: 13. D oes the patient have: a) A power of attorney ? b) A healthcare power of attorney ? c) ? Yes No Unknown Yes No Unknown Yes No Unknown 14. Does the patient have any of the following coverages? a) Health insurance ? b) Medicare ? c) Medicaid ? d) ? Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown 15. Does the patient have a primary caregiver ? Yes No If yes, provide caregiver name, address, and relationship to the patient . 16. Please identify the persons wi American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 FORM #539GC (01/2019) 62-5-303, 62-5-303D, 62-5-403, 62-5-403B, 62-5-403D, 62-5-304, 62-5-407, 62-5-407(B) 17. BASED UPON MY EVALUATION OF THIS PATIENT: a. I DO NOT 2 I do not find that he/she lacks the ability to effectively receive, evaluate, and respond to in form ation or make or communicate decisions such that a person, even with appropriate, reasonably available support and assistance cannot: a) meet the essential requirements for his/her physical health, safety, or self - care, necessitating the need for a guardian ; or b) manage his/her property or financial affairs or provide for his/her support of for the support of his/her legal dependents, necessitating the need for a protective order. b. I DO bility to effectively receive, evaluate, and respond to in form ation or make or communicate decisions such that a person, even with appropriate, reasonably available support and assistance cannot: a) meet the essential requirements for his/her physical health , safety, or self - care, necessita ting the need for a guardian; or b) manage his/her property or financial affairs or provide for his/her support of for the support of his/her legal dependents, necessitation the need for a protective order. Use this space to provide explanations or additional comments. SWORN to before me this day of Signature: , 20 . Print Name: Credentials : ( e.g. , M.D., Ph.D., D.O., R.N.) Print Name: Address : Notary Public for: (State) Telephone : My Commission Expires: (Date) 2 As defined in S.C. Code Ann. 247 62-5-formation or make or communicate decisions such that a person, even with appropriate, reasonably available support and assistance cannot: a) meet the essential requirements for his/her physical health, safety, or self-care, necessitating the need for a guardian; or b) manage his property or financial affairs or provide for his support of for the support of his legal dependents, necessitating the need for a protective order. American LegalNet, Inc. www.FormsWorkFlow.com