2754 REPORT OF PHYSICIAN (Rev. 11/01/01) CCP 0211 A (Please print legibly or type) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS ESTATE OF __________________________________________________ Alleged Disabled Person } No. _______________________________________ Docket __________________________________ Page _____________________________________ REPORT _____________________________________________, a physician licensed to practice medicine in all its branches in the State of Illinois, submits the following report on _______________________________________________________, an allegedly disabled person, based on an examination of the respondent on ___________________________, _______. NOTE: The examination must have occurred no earlier than three months before the petition for guardianship is filed. (Attach additional sheet if necessary) 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 condition, adaptive behavior, and social skills: 3. State whether, in your opinion, the respondent is TOTALLY or only PARTIALLY incapable 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 habilitation plan. Include reasons for your opinion. 5. Provide a statement describing the certification, license, or other credentials of the physician preparing this report. (OVER) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS REPORT OF PHYSICIAN (Rev. 11/01/01) CCP 0211B ___________________________________________ (Print or Type Physician's Name) ___________________________________________ (License No.) Signed: *____________________________________________ *See reverse side Address: ___________________________________________ City/State/Zip: ______________________________________ Telephone: __________________________________________ *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. Evaluations upon which the report is based must have been performed within 3 months of the date of the filing of petition. 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 __________________________________________________________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form