IN THE CIRCUIT COURT OF THE TENTH JUDICIAL CIRCUIT COUNTY, ILLINOIS IN THE MATTER OF THE ESTATE OF (Alleged Disabled Person): Name: Case No.: Address: City, State, Zip: Date of Birth: PHYSICIAN222S REPORT , a physician licensed to practice medicine in all its branches in the State of Illinois, submits the following report on the above alleged disabled person. 1. Describe the nature and the type of respondent222s disability and an assessment of how the disability impacts on the ability of the respondent to make decisions or to function independently: 2. Describe the respondent222s mental and physical condition and, where appropriate, describe educational condition, adaptive behavior, and social skills which have been performed within 3 months of the date of filing to this petition: American LegalNet, Inc. www.FormsWorkFlow.com 3. Your opinions as to whether guardianship is needed, the type and scope of the guardianship needed, and the reasons therefore: 4. Your recommendation as to the most suitable living arrangements and, where appropriate, treatment or habilitation plan for the respondent and the reasons therefore: Date: Physician222s Name (please print): Signature of Physician: Address: City, State, Zip: American LegalNet, Inc. www.FormsWorkFlow.com Case No.: This report must contain the signature of all person(s) who performed the evaluations upon which the report is based, one of whom must be a licensed physician, and a statement of the certification, license or other credentials that qualify the evaluators who prepared this report. 1. Name: Signature: Address-City, State, Zip: Credentials: 2. Name: Signature: Address-City, State, Zip: Credentials: 3. Name: Signature: Address-City, State, Zip: Credentials: American LegalNet, Inc. www.FormsWorkFlow.com