STATE OF SOUTH CAROLINA COUNTY OF: IN THE MATTER OF: ) ) ) ) ) ) IN THE PROBATE COURT EXAMINER’S REPORT CASE NUMBER: Please answer the following questions concerning the above person. Please provide details at the end of this form or an attached sheet of paper. 1. Have you treated this person before If yes, give brief history. 2. Has this person ever been rated or found: disabled mentally ill or incompetent chemically dependent 3. No No No Unknown Unknown Unknown Yes Yes Yes Yes Yes Yes Yes No No No No No No No Unknown Unknown Unknown Unknown Unknown Unknown Unknown Yes Yes Yes Yes Yes Yes No No No No No No Unknown Unknown Unknown Unknown Unknown Unknown Yes Yes Yes Yes Yes No No No No No Unknown Unknown Unknown Unknown Unknown Has the above person had in the last six months: hospitalization(s) therapy or treatment inpatient or outpatient surgery major medical test(s) psychological or psychiatric testing 6. Yes Yes Yes Would the above person benefit from: further education further training therapy of some sort medical aids or equipment an operation or medical procedure(s) structured living arrangements 5. No Can the above person: care for self (personal hygiene) prepare meals and/or clean house maintain bank accounts or funds pay bills live independently operate a car take medications unsupervised 4. Yes In your opinion, does this person have the mental or physical capacity to effectively manage his/her property and financial affairs Yes No and /or make necessary daily living and health care decisions FORM #538PC (2/2004) 62 5-303, 62-5-407 Yes No Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com 7. To your knowledge does this person have: a power of attorney a health care power of attorney or a “living will” 8. Yes Yes Yes Unknown Unknown Unknown Yes Yes Yes Yes No No No No Unknown Unknown Unknown Unknown Does the above person have any of the following coverages? health insurance medicare medicaid veteran’s health care 9. No No No Does this person have a primary caretaker? Yes No Unknown If yes, please give available information on name, address, and relationship to above person. SWORN to before me this day of Date: , 20 Examiner’s Signature Notary Public for South Carolina Examiner’s Name My Commission Expires: Use this space for explanations or additional comments. FORM #538PC (2/2004) Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com