251 2018 Nevada Supreme Court Page 1 of 6 226 Physician222s Certificate PHYSICIAN222S CERTIFICATE WITH NEEDS ASSESSMENT (Please answer all questions) I, , am qualified to complete this form because: Physician222s Full Name (please print legibly)I last examined , an adult, on , Patient222s Full Name (223Patient224) Date of Exam at . I have been the Patient222s physician * Before the court can appoint a guardian, a licensed physician must complete an assessment of the Patient222s needs that identifies limitations of capacity and how such limitations affect the Patient222s ability to maintain safety and basic needs. American LegalNet, Inc. www.FormsWorkFlow.com 251 2018 Nevada Supreme Court Page 2 of 6 226 Physician222s Certificate E. The Patient222s physical diagnosis (DSM or ICD Diagnoses) and condition is: Prognosis is: Severity/Degree is: ( check one) Mild Moderate Severe F. The Patient222s mental diagnosis (DSM or ICD Diagnoses) and condition is: Prognosis is: Severity/Degree is: ( check one) Mild Moderate Severe G. Which of the following descriptions apply to the patient222s degree of cognitive impairment ( check all that apply)? The patient has a sufficient loss or total loss of executive function resulting in a barrier to meaningful understanding or rational response. The Patient is able to make independently some but not all of the decisions necessary for his or her own care and management of property. The patient is unable to execute on desires, preferences, or stated goals, preventing the ability to pursue the patient222s own best interest. The patient is unable to receive or evaluate information. The patient is unable to make or communicate decisions to such an extent that the patient lacks the ability to meet essential requirements for physical health, safety, or self-care without proper assistance. None of the above. H. Is the Patient facing an immediate need for medical attention? ....................... Yes No If YES, is the Patient unable to respond to the need for medical attention? ..... Yes No If YES, explain the immediate attention needed and why the Patient is unable to respond: I. Is the Patient facing a substantial and immediate risk of physical harm? ......... Yes No If YES, is the Patient unable to respond to that risk of physical harm? ............ Yes No If YES, explain the immediate risk and why the Patient is unable to respond: American LegalNet, Inc. www.FormsWorkFlow.com 251 2018 Nevada Supreme Court Page 3 of 6 226 Physician222s Certificate J. Is the Patient facing a substantial and immediate risk of financial loss? .......... Yes No If YES, is the Patient unable to respond to that risk of financial loss? ............. Yes No If YES, explain the immediate risk and why the Patient is unable to respond: K. Does the Patient present a danger to himself/herself? ..................................... Yes No Does the Patient present a danger to others? .................................................... Yes No If YES, explain: L. Has the Patient been subjected to abuse, neglect, or exploitation? ................... Yes No If YES, explain: M. Is the Patient capable of living independently? ( check one) Yes, without assistance Yes, with assistance No If WITH ASSISTANCE, describe the assistance needed; if NO, explain why not: N. Attached to this certificate is ( check all that apply, if applicable): A copy of my report of the above exam which includes my findings, opinion, and diagnosis regarding the Patient and his/her mental condition and/or capacity. A copy of the Patient222s chart notes which support and/or detail my findings, opinion, and diagnosis regarding the Patient and his/her mental condition and/or capacity. A letter, signed by me, detailing my findings, opinion, and diagnosis regarding the Patient and his/her mental condition and/or capacity. SECTION 2: Ability to Appear at Hearing A. Would the Patient222s attendance at a hearing for appointment of a guardian be detrimental to the Patient222s mental health? ................................................................................ Yes No If YES, why? B. Would attending the hearing for appointment of a guardian be detrimental to the Patient222s physical health? ................................................................................................. Yes No If YES, why? American LegalNet, Inc. www.FormsWorkFlow.com 251 2018 Nevada Supreme Court Page 4 of 6 226 Physician222s Certificate C. Is the patient able to appear at a court hearing? ................................................. Yes No If NO, why not? D. Would the patient comprehend the reason for a hearing? .................................. Yes No E. Would the patient contribute to a hearing? ......................................................... Yes No SECTION 3: Limitations, Abilities, and Needs A. The Patient222s level of needed supervision is as follows: Locked Facility 24-hour supervision Independent living with some supervision No supervision No supervision when taking medication B. My opinion as to the Patient222s everyday functions is as follows: Independent Needs Support Needs Substantial Assistance Needs Total Care Unknown CARE OF SELF (Activities of Daily Living (ADLs) and related activities) Bathe and shower Personal hygiene and grooming (e.g., brushing teeth, hair) Dress self Toilet hygiene (getting to toilet, cleaning self, getting back up) Functional mobility (e.g., walking, transferring to/from bed or chair) Feed self and eat for adequate nutrition Identify physical abuse or neglect and protect self from harm FINANCIAL Manage, deposit, withdraw, dispose of, and invest money and assets Protect, and spend small amounts of cash Employ persons to advise or assist him/her Identify financial exploitation, coercion, undue influence Protect self from financial exploitation, coercion, undue influence Give gifts and donations American LegalNet, Inc. www.FormsWorkFlow.com 251 2018 Nevada Supreme Court Page 5 of 6 226 Physician222s Certificate Independent Needs Support Needs Substantial Assistance Needs Total Care Unknown MEDICAL Give/withhold medical consent to medical, dental, psychological Admit self to health facility Make or change an advance directive or healthcare power of attorney Manage medications Contact help if ill or in medical emergency HOME AND COMMUNITY LIFE Choose/establish residence Maintain reasonably safe and clean shelter Drive or use public transportation Prepare food/meals, cleanup Shop for groceries and necessities Use telephone or other forms of communication Make and communicate choices about roommates Avoid environmental dangers such as stove, poisons Maintain and pay household bills, utilities, mortgage/rent, taxes SECTION 4: Civil and Legal A. In my opinion, the Patient lacks the capacity necessary to ( check all that apply): Enter into a contract, financial commitment, or lease arrangement Make or modify a will or power of attorney Participate in mediation B. Is the Patient capable of driving? .............................................. Yes No Uncertain C. Would the Patient present a risk or threat to self or others if Patient were to own or purchase a firearm? .................................................................................. Yes No Uncertain D. Does the Patient have the capacity necessary to understand and complete voter registration forms and vote? ......................................................................... Yes No Uncertain American LegalNet, Inc. www.FormsWorkFlow.com 251 2018 Nevada Supreme Court Page 6 of 6 226 Physician222s Certificate SECTION 5: Remarks and Recommendations A. If you have any remarks concerning other sections, or if you believe the court should be aware of other concerns about the Patient which are not included above, please explain: B. If you have any recommendations for needed treatment or services which are not included above, please explain: (This certificate must be signed by the physician, agency employee, or other person identified at the top of page 1 of the certificate.) I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct.