Physician222s Evaluation/ Conservatorship PC - 370 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL Physician222s Evaluation/Conservatorship PC - 370 Page 1 of 4 RECEIVED: Instructions: 1) A physician may be requested to complete this form in connection with an involuntary proceeding for the appointment of a conservator of the person or estate, or review of a conservatorship previously established by the Probate Court. 2)The named physician must be licensed to practice medicine in Connecticut and must have personallyexamined the patient on the Date of Examination listed below. 3)Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number Patient Date of Examination Place of Examination Physician (Name, address and telephone number) Connecticut Medical License No. Practicing Psychiatrist Yes No Professional relationship to patient: Consultation/Evaluation Treating Physician If you are a treating physician, how long have you treated this patient? 1.Capacity Is the patient222s capacity to make financial decisions impaired? Yes No Is the patient222s capacity to make personal decisions impaired? Yes No If the answer to either question is yes, please complete all sections below. Please give specific examples of recent history known to you that contribute to your answers below. If more space is required, use additional sheets. American LegalNet, Inc. www.FormsWorkFlow.com Physician222s Evaluation/ Conservatorship PC - 370 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Physician222s Evaluation/Conservatorship PC - 370 Page 2 of 4 1a. In my opinion, the patient has: (Check all that apply.) mental illness cognitive deficiency physical illness or physical disability addiction other (specify) that results in the patient being unable to receive or evaluate information or make or communicate decisions about the patient222s personal or financial affairs as indicated above. 1b. Describe the patient222s current status or symptoms stemming from this condition. 1c. What is the current medical diagnosis? 1d. Is the current condition transitory or permanent in nature? Explain. 1e. Does the illness or condition affect the patient222s ability to seek or obtain medical care? Yes No If yes, give specific examples. 1f. Does the illness or condition affect the patient222s ability to secure and maintain a safe living environment? Yes No If yes, give specific examples. Yes No 1g. Does the illness or condition affect the patient222s ability to independently manage financial affairs? If yes, give specific examples. 1h. Does the illness or condition raise safety concerns, including the patient222s ability to seek Yes No protection from physical abuse or financial exploitation? If yes, give specific examples. American LegalNet, Inc. www.FormsWorkFlow.com Physician222s Evaluation/ Conservatorship PC - 370 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Physician222s Evaluation/Conservatorship PC - 370 Page 3 of 4 2.Medications2a. List all medications prescribed. Is the patient capable of managing his/her medications? Yes No 2b. Do any of these medications affect mental functioning? Yes No Uncertain If yes, give specific examples. 3.Treatments and Interventions 3a. Does the patient require hospitalization or additional medical treatment or intervention? Yes No If yes, explain. 3b. Is the patient capable of weighing the benefits and risks of the medical treatment or other alternative interventions recommended in 3a. above? Yes No If yes, explain. 4.Additional information Include any other relevant information you believe should be presented to the court. American LegalNet, Inc. www.FormsWorkFlow.com Physician222s Evaluation/ Conservatorship PC - 370 REV. 4 /19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of Physician222s Evaluation/Conservatorship PC - 370 Page 4 of 4 5.Review of conservatorship If this form was requested in conjunction with a review of the conservatorship under C.G.S. section 45a-660, please also complete this section. terminated. In my opinion, the conservatorship should be continued modified Specify your reasons for your opinion. If more space is required, use additional sheets. I hereby certify that: I am a physician licensed to practice medicine in the state of Connecticut. I personally examined the respondent on the above - referenced date. Signature of Examining Physician Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com