IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS - IN PROBATE Estate of CASE NO: REPORT OF PHYSICIAN , a physician licensed to practise medicine in all its branches in the State of Illinois, submits the following report on alleged disabled person, based on an examination of the respondent on , 20 . NOTE: The examination must have occurred no earlier than three months before the petition for guardianship is filed. 1. Describe the nature and type of the respondent's disability: (Please state underlying diagnosis, as well as manifestations of disability.) 2. Describe 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 FINACIAL decisions, and if the latter, the kinds of decisions which the respondent can and cannon make. Include the response 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. *Signed: Address: City, State, & Zip: Telephone: (SEE REVERSE SIDE) American LegalNet, Inc. www.FormsWorkFlow.com Form 40D (Revised 12/16) CVPA * 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 3 months of the date of the filing of the petition. Names and signatures of other persons who performed evaluations upon which this report is based: Name Address City, State, & Zip Signature Name Address City, State, & Zip Signature Name Address City, State, & Zip Signature ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com 40d 12/16