REPORT OF PHYSICIAN STATE OF ILLINOIS 3844 (Rev 10/16) UNITED STATES OF AMERICA COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT IN RE THE ESTATE OF CASE NUMBER ALLEGED DISABLED PERSON REPORT OF PHYSICIAN File Stamp Here , a physician licensed to practice medicine in all branches in the State of Illinois, submits the following report on disabled person, based on an examination of the respondent on . an alleged NOTE: The examination must have occurred no earlier than three (3) months before the Petition for Guardianship is filed. 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 conditions, 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 rehabilitation plan. Include the reason(s) for your opinion. Please indicate what restrictions are reasonably necessary to protect the assets and/or ensure the safety of the alleged disabled person. Print or type physician's name License Number: Address: City/State/Zip: Telephone Number: PAGE 1 OF 2 OVER Signature CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 American LegalNet, Inc. www.FormsWorkFlow.com REPORT OF PHYSICIAN 3844 (Rev 10/16) 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. Evaluation on which the report is based must have been performed within three (3) months of the date of the filing of the petition. 5. Provide a statement describing the certification, license or other credentials of the physician preparing this report. Names and signatures of other person(s) 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 Name: DuPage Attorney Number: Attorney for: Address: City/State/Zip: Telephone Number: Email: Pro Se CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com