IN THE CIRCUIT COURT FOR THE SIXTEENTH JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS Case No. ____________________ Estate of: (Alleged Disabled Person) Name: Address: City: State: Zip: (file stamp here) PHYSICIAN’S REPORT ______________________________________________________, a physician licensed to practice medicine in all its branches in the State of Illinois, submits the following report on the above named, alleged to be a disabled person, based on an examination of the respondent on ____________________, 20_____. 1. Describe the nature and type of the respondent’s disability: 2. Describe the respondent’s mental and physical condition and, where appropriate, described education 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 of habilitation plan. Include the reasons for your opinion. NOTICE 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 on which the report is based must have been performed within three (3) months of the date of filing the petition. The names and signatures of all persons who have performed evaluations upon which this report is based should be listed on the reverse side hereof. Signed _____________________________ Address____________________________ City & State_________________________ Telephone___________________________ Probate12 9/12/05 American LegalNet, Inc. www.FormsWorkflow.com