Physician's Certificate of Medical Examination Revision September 2015 In the Matter of the Guardianship of _____________________________________, an Alleged Incapacitated Person For Court Use Only Court Assigned:__________________ To the Physician This form is to enable the Court to determine whether the individual identified above is incapacitated according to the legal definition (on page 3), and whether that person should have a guardian appointed. 1. General Information Physician's Name Office Address YES NO __________________________________________ Phone: (______)_________________ __________________________________________________________________________ __________________________________________________________________________ I am a physician currently licensed to practice in the State of Texas. Proposed Ward's Name ______________________________________________________________________ Date of Birth _________________________________ Age___________ Gender M F Proposed Ward's Current Residence: __________________________________________________________ I last examined the Proposed Ward on _________________________________, 20______ at: a Medical facility the Proposed Ward's residence Other: __________________________ YES NO YES NO YES NO The Proposed Ward is under my continuing treatment. Before the examination, I informed the Proposed Ward that communications with me would not be privileged. A mini-mental status exam was given. If "YES," please attach a copy. 2. Evaluation of the Proposed Ward's Physical Condition Physical Diagnosis: ___________________________________________________________________________ a. Severity: Mild Moderate Severe b. Prognosis: ___________________________________________________________________________ c. Treatment/Medical History: _________________________________________________________________ 3. Evaluation of the Proposed Ward's Mental Functioning Mental Diagnosis: ___________________________________________________________________________ a. Severity: Mild Moderate Severe b. Prognosis: ___________________________________________________________________________ c. Treatment/Medical History: _________________________________________________________________ If the mental diagnosis includes dementia, answer the following: YES NO ---- It would be in the Proposed Ward's best interest to be placed in a secured facility for the elderly or a secured nursing facility that specializes in the care and treatment of people with dementia. YES NO ---- It would be in the Proposed Ward's best interest to be administered medications appropriate for the care and treatment of dementia. YES NO ---- The Proposed Ward currently has sufficient capacity to give informed consent to the administration of dementia medications. d. Possibility for Improvement: YES NO ---- Is improvement in the Proposed Ward's physical condition and mental functioning possible? If "YES," after what period should the Proposed Ward be reevaluated to determine whether a guardianship continues to be necessary? _______________________________________________ Physician's Certificate of Medical Examination Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 4. Cognitive Deficits a. The Proposed Ward is oriented to the following (check all that apply): Person Time Place Situation b. The Proposed Ward has a deficit in the following areas (check all areas in which Proposed Ward has a deficit): --- Short-term memory --- Long-term memory --- Immediate recall --- Understanding and communicating (verbally or otherwise) --- Recognizing familiar objects and persons --- Solve problems --- Reasoning logically --- Grasping abstract aspects of his or her situation --- Interpreting idiomatic expressions or proverbs --- Breaking down complex tasks down into simple steps and carrying them out c. YES NO -- The Proposed Ward's periods of impairment from the deficits indicated above (if any) vary substantially in frequency, severity, or duration. 5. Ability to Make Responsible Decisions Is the Proposed Ward able to initiate and make responsible decisions concerning himself or herself regarding the following: YES NO ---- Make complex business, managerial, and financial decisions YES NO ---- Manage a personal bank account If "YES," should amount deposited in any such bank account be limited? YES NO YES NO ---- Safely operate a motor vehicle YES NO ---- Vote in a public election YES NO ---- Make decisions regarding marriage YES NO ---- Determine the Proposed Ward's own residence YES NO ---- Administer own medications on a daily basis YES NO ---- Attend to basic activities of daily living (ADLs) (e.g., bathing, grooming, dressing, walking, toileting) without supports and services YES NO ---- Attend to basic activities of daily living (ADLs) (e.g., bathing, grooming, dressing, walking, toileting) with supports and services YES NO ---- Attend to instrumental activities of daily living (e.g., shopping, cooking, traveling, cleaning) YES NO ---- Consent to medical and dental treatment at this point going forward YES NO ---- Consent to psychological and psychiatric treatment at this point going forward 6. Developmental Disability YES NO ---- Does the Proposed Ward have developmental disability? If "NO," skip to number 7 below. If "YES," answer the following question and look at the next page. Is the disability a result of the following? (Check all that apply) YES NO ---- Intellectual Disability ? YES NO ---- Autism? YES NO ---- Static Encephalopathy? YES NO ---- Cerebral Palsy? YES NO ---- Down Syndrome? YES NO ---- Other? Please explain __________________________________________________ Answer the questions in the "Determination of Intellectual Disability" box below only if both of the following are true: (1) The basis of a proposed ward's alleged incapacity is intellectual disability. and Physician's Certificate of Medical Examination Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com (2) You are making a "Determination of Intellectual Disability" in accordance with rules of the executive commissioner of the Health and Human Services Commission governing examinations of that kind. If you are not making such a determination, please skip to number 7 below. "DETERMINATION OF INTELLECTUAL DISABILITY" Among other requirements, a Determination of Intellectual Disability must be based on an interview with the Proposed Ward and on a professional assessment that includes the following: 1) a measure of the Propose