HEALTH PROFESSIONAL’S REPORT To the Health Professional: Please complete every question on this Report, date and sign it personally, and deliver it to me, the guardian and/or conservator, at the address below. (1) Guardian and/or Conservator’s Name: Street Address: City, State, Zip: Phone Number: (2) Ward’s Name: (3) Case Number: GC Diagnosis: List and describe the client’s diagnosis: Functional Impairments: Impairment Effects on Client’s Decisions or Communication Daily Living: Check the box next to each task the client can perform with minimal or no direction: [ ] obtaining food [ ] obtaining housing [ ] living alone [ ] taking medication [ ] paying bills [ ] driving Page 1 of 2 Revised May 2005 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com Medication: List all medications the client receives. Medication Dosage Effects on Behavior Prognosis: Describe your prognosis for improvement in the client’s condition: Rehabilitation: Describe your recommendation for the most appropriate rehabilitation or care plan: Other: List any other relevant information: Date: Page 2 of 2 Revised May 2005 Health Professional’s Signature: Printed Name: Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com