Report of Examination (Licensed Physician) 24751.45(13), Wis. Stats. INSTRUCTIONS This report will be used in a legal proceeding to determine if this subject individual should be involuntarily committed for treatment. This r eport must be received by the court at least 96 hours prior to the schedul ed hearing excluding Saturdays, Sundays and legal holidays. Please answer the questions to the best of your ability to a reasonable degree of medical certainty. Any questions that Type or print your answers neatly. You may supplement this report with attachments. Y ou must inform the subject individual of his/her rights as set forth in the Report of Examination prior to the examination. DEFINITION Alcoholism A disease which is characterized by the dependency of a person on the drug alcohol, to the extent that the and his/her social or economic functioning is substantially disrupted. (This Instruction Page should NOT be submitted to the Court) American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL COURT RECORD ME-940, 02/16 Report of Examination 24751.45(13), Wis. Stats. 24751.45(13), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name of Subject Individual Date of Birth Amended Report of Examination 247 51.45(13), Wis. Stats. Case No. Name of Examiner: Psychiatrist Licensed Physician Date of Examination: Time spent with subject individual : Place of Examination: If you were unable to personally examine the subject individual, please explain: Collateral sources used as part of the examination Records: Interviews with others: Other: Brief History: [Report relevant social and medical history , including information from collateral sources ] Prior to the examination, d id you inform the subject individual : A. Of the nature and reasons for the examination? Yes No B. Th at th e examination was ordered by the Court? Yes No C. Th at th e findings of the examination would be made available to the C ourt? Yes No D. Of his/her right t o remain sile nt during the course of the exam ination? Yes No E. That y ou are re quired to make a report to the Court even if he/she remains silent? Yes No Did the subject individual appear to understand his/her rights? Yes No American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL COURT RECORD ME-940, 02/16 Report of Examination 24751.45(13), Wis. Stats. 24751.45(13), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 2 . resentation A. the examination ; general appearance; motor behavior; facial expressions; vo ice and speech; affect and mood ) B. sensorium: (Orientation; memory; insight; judgment; abstract thin king; general fund of knowledge ) 3 . I have an opinion to a reasonable medical certainty that the subject individual: (Explain basis of answer) A. Habitually lacks self - control as to the use of alcohol beverages and uses alcohol beverages to the extent that health is subst antially impaired or endangered. Yes No B. Uses alcohol beverages to the extent that social or economic functio ning is substantially disrupted. Yes No C. Has a relationship between the alcohol condition and a pattern of conduct during the 12 - month period immediately proceeding the time of petition which is da ngerous to the person or others. Yes No EXAMINATION 1. A. Summarize any relevant information obtained from the subject individual pertaining to past history and present events: B. Summarize any relevant information obtained from the subject individual pertaining to the incidents leading to detention , or commitment if the subject individual is currently under a commitment order: American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL COURT RECORD ME-940, 02/16 Report of Examination 24751.45(13), Wis. Stats. 24751.45(13), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 D. Has an extreme likelihood that the pattern of conduct will continue or repeat itself without intervention of involuntary treatment. Yes No E. Is suitable for any al ternative other than commitment. Yes No 4 . Is the county department able to provide appropriate and effective treatment for the subject individual? Yes No 5 . A dditional Comments/Recommendations: TO THE COURT: I am the undersigned examiner and report that I have by examination satisfied myself as to the condition of [Subject Individual] . The results of my examination are contained in this document. DISTRIBUTION: 1. Court 2. 3. Corporation Counsel Psychiatrist Physician Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com