IN THE PROBATE DIVISION, CIRCUIT COURT, ST. LOUIS COUNTY, MISSOURI In the Matter of: __________________________________________ A Person Alleged to be Incapacitated and Disabled Estate Number: _________________ Exhibit F - PHYSICIAN'S ANSWERS TO INTERROGATORIES COMES NOW, Dr. _________________________________, and for his/her Answers to Petitioner's First Interrogatories, states to the Court as follows: INTERROGATORY NO. 1: Please state your full name, and give a brief narrative summary of your education, qualifications, licensure and experience in the practice of medicine as a physician. ANSWER: Education: Qualifications, Licensure: Experience: CCPR005 ­ 11/10 2 American LegalNet, Inc. www.FormsWorkFlow.com INTERROGATORY NO. 2: Please state whether or not respondent has ever been your patient, and if so please specify the following: A. B. C. Date of First Examination: _____________________ Date of Last Examination: _____________________ Diagnosis and Prognosis of Patient's Present Physical and Mental Condition (if possible, please include DSM-IV Rev. axes and diagnoses): ANSWER: CCPR005 ­ 11/10 3 American LegalNet, Inc. www.FormsWorkFlow.com INTERROGATORY NO. 3: Please state what medications are currently being prescribed for respondent. ANSWER: CCPR005 ­ 11/10 4 American LegalNet, Inc. www.FormsWorkFlow.com INTERROGATORY NO. 4: Based on your stated qualifications and personal examination, please state your medical opinion of the following: A. Is the respondent an incapacitated person in that he or she is unable to receive and evaluate information or to communicate decisions to such an extent that he or she lacks the capacity to meet the essential requirements for food, clothing, shelter, safety or other care such that serious physical injury, illness or disease is likely to occur? ANSWER: If you answer is affirmative, the answer must be "yes" or "yes, the respondent is partially unable..." It is NOT sufficient to say that the person may "benefit" from a guardian; that a guardian would be "helpful," "advisable," or anything similar. The doctor MUST be able, with medical integrity, to say that this person's condition makes the person UNABLE to receive and evaluate information or to communicate decisions to such an extent that he or she lacks capacity to meet essential requirements for food, clothing, shelter, safety or other care such that serious physical injury, illness, or disease is likely to occur. Anything short of that is insufficient. CCPR005 ­ 11/10 5 American LegalNet, Inc. www.FormsWorkFlow.com B. Is the respondent a disabled person in that he or she is unable to receive and evaluate information or to communicate decisions to such an extent that he or she lacks the ability to manage his or her financial resources? ANSWER: Again, if your answer is affirmative, the answer must be "yes" or "yes, the respondent is partially unable..." It is NOT sufficient to say that the person may "benefit" from a conservator; that a conservator would be "helpful," "advisable," or any other similar word. The doctor MUST be able, with medical integrity, to say that this person's condition makes the person UNABLE to receive and evaluate information or to communicate decisions to such an extent that he or she lacks capacity to make financial decisions. Anything short of that is insufficient. CCPR005 ­ 11/10 6 American LegalNet, Inc. www.FormsWorkFlow.com If the answer to A and/or B is yes, what mental and/or physical condition is the reason for this incapacity and/or disability (if possible, please include DSM-IV Rev. axes and diagnoses)? ANSWER: There MUST be a connection between the diagnosis and the incapacity or disability. (For example, dementia, Alzheimer's type, prevents respondent from being able to remember to take medications on time, or even to remember what medications to take, or even that the person requires any medications.) CCPR005 ­ 11/10 7 American LegalNet, Inc. www.FormsWorkFlow.com INTERROGATORY NO. 5: What is the least restrictive environment (e.g., skilled nursing facility, intermediate care facility, residential care facility I or II, group home, assisted living center, etc.) in which the respondent must presently be restrained in order to prevent from injuring himself/herself and/or others and to provide him or her with such care, habilitation, and treatment as are appropriate considering his or her physical and mental condition? ANSWER: *This report is made by a mandatory reporter under section 660.255 RSMo, regarding an eligible adult who presents a likelihood of suffering serious physical harm and who is in need of protective services. {"Any person having reasonable cause to suspect that an eligible adult presents a likelihood of suffering serious physical harm [i.e., a substantial risk that physical harm to an eligible adult will occur because of his or her failure or inability to provide for his or her essential human needs as evidenced by acts or behavior which has caused harm or which gives another person probable cause to believe that the eligible adult will sustain such harm] and is in need of protective services shall report such information to the department [of health and senior services]."} *This report is made by a mandatory reporter under section 198.070 RSMo, regarding abuse, neglect of a resident of a long term care facility. *This report is made by a mandatory reporter under section 660.300 RSMo, regarding abuse, neglect or financial exploitation of a client of an in-home service agency. Dr. _____________________________________ CCPR005 ­ 11/10 8 American LegalNet, Inc. www.FormsWorkFlow.com ACKNOWLEDGMENT State of Missouri ) ) ss County of _______________) Now on this ______ day of ______________, 20___, comes Dr. __________________, Being duly sworn and upon oath states that he/she has read and understands all the statements and allegations contained in the foregoing document and that the same are true according to his/her best information, knowledge and belief. Subscribed and sworn to before me this _________ day of ________________, 20____. __________________________________________ Notary Public My commission expires: _______________ CCPR005 ­ 11/10 9 American LegalNet, Inc. www.FormsWorkFlow.com