DATE FILEDFORCOURT USE ONLY Name of IndividualBeing AssessedCurrent Street AddressCity/Town StateZipCodePhoneNumberStreet AddressCity/TownStateZipCodePhoneNumber Instructions for CompletionThis document will be used by a Probate Court to determine whether to appoint a guardian to assist this individual in some or all areas of decision-making.To a physician completing this document: The individual222s treating physician must complete this document. If there is any information of which the treating physician does not have direct those individuals must be listed on the Summary.To a non-physician completing this document:individual being assessed may also complete this document. If there is information of which a non-The document must be signed and dated by the person completing it. It does not need to be notarized. DECISION-MAKING ASSESSMENT TOOL(FOR LIMITED GUARDIANSHIP OR GUARDIANSHIP)RIGL 35-15-4 & RIGL 33-15-47 State of Rhode Island and Providence PlantationsProbate CourtPage 1 of 5 STATE OF RHODE ISLANDCounty ofEstate ofAlias PROBATE COURT OF THECity or Town ofNo. American LegalNet, Inc. www.FormsWorkFlow.com A. BIOLOGICAL ASSESSMENTTHE FOLLOWING IS BASED UPON A PHYSICAL EXAMINATION CONDUCTED BY ME ON (DATE): 1. DIAGNOSIS and PROGNOSIS:2. MEDICATIONS (PLEASE LIST):3. CURRENT NUTRITIONAL STATUS:Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 B. PSYCHOLOGICAL ASSESSMENT1. MEMORY (CHECK ONE):3. JUDGEMENT (CHECK ONE): A. Intact B. Mild Impairment C. Moderate Impairment D. Severe Impairment A. Intact B. Able to Make Most Decisions C. Impaired D. Gross Impairment2. ATTENTION (CHECK ONE):4. LANGUAGE (CHECK ONE): A. Intact B. Mild Impairment C. Shifting/Wandering D. Delirium E. Unresponsive A. Intact C. Impairment in Comprehension/Speech Mild/Moderate/ Severe D. Completely Unresponsive 5. EMOTION (CHECK ALL THAT APPLY):A. ANXIETY/DEPRESSION 1. None 4. Severe Symptoms with Sleep/Appetite/Energy Disturbance 5. Suicidal/HomicidalB. OTHER 2. Delusions/Hallucinations 3. Unresponsive American LegalNet, Inc. www.FormsWorkFlow.com C. SOCIAL ASSESSMENT1. MOBILITY (CHECK ALL THAT APPLY): B. Drives Car or Uses Public Transportation C. Independent Ambulation in Home Only D. Walker/Cane 2. SELF CARE (CHECK ALL THAT APPLY): 1. Meals 2. Bathing 3. Dressing 4. Toileting/Feeding3. CARE PLAN MAINTENANCE (CHECK ALL THAT APPLY): A. No Active Problem C. Actively Cooperative D. Passively Cooperative E. Passively Uncooperative F. Actively UncooperativeA. SUPPORT 1. Very Good Supportive Network 2. Some Support from Family & Friends 3. No or Limited Support from Family & Friends 4. Needs Community Support 5. Isolated/HomeboundB. SOCIAL SKILLS 1. Very Good Social Skills 2. Good Social Skills 3. Interacts with Prompting 4. IsolatedPage 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 D.SUMMARYdecision-making ability is as follows:1.Please describe as fully as you can the individual222s decision-making ability in each of the following areas:A.FINANCIAL MATTERS:B.HEALTH CARE MATTERS:C.RELATIONSHIPS:D.RESIDENTIAL MATTERS:2.Please indicate your opinion regarding whether the individual needs a substitute decision-maker in any of the following areas (CheckA.FINANCIAL MATTERSB.HEALTH CARE MATTERS C.RELATIONSHIPSD.RESIDENTIAL MATTERS Yes Yes Yes Yes No No No No Limited Limited Limited LimitedE.OTHER: (if there are other areas in which you think the individual lacks decision-making ability or has limited decision-makingName ofPhysician(Print or Type)TitleSignatureDateName ofNon-Physician (Print or Type)TitleSignatureDateNames and titles of other who assisted in preparation of this Assessment:NameTitle PHYSICIAN SIGN HERE American LegalNet, Inc. www.FormsWorkFlow.com