Free $$WRK1$$ - Illinois

2754 REPORT OF PHYSICIAN

(Please print legibly or type)

(Rev. 11/01/01) CCP 0211 A

IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS ESTATE OF

__________________________________________________
Alleged Disabled Person

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No. _______________________________________ Docket __________________________________ Page _____________________________________

REPORT _____________________________________________, a physician licensed to practice medicine in all its branches in the State of Illinois, submits the following report on _______________________________________________________, an allegedly disabled person, based on an examination of the respondent on ___________________________, _______.
NOTE: The examination must have occurred no earlier than three months before the petition for guardianship is filed.
(Attach additional sheet if necessary)

1. Describe the nature and type of the respondent's disability and provide an assessment of how the disability impacts on the ability of the respondent to make decisions or to function independently. (Please state underlying diagnosis, as well as manifestations of disability.)

2. Provide an analysis and results of evaluations of the respondent's mental and physical condition and, where appropriate, describe educational condition, adaptive behavior, and social skills:

3. State whether, in your opinion, the respondent is TOTALLY or only PARTIALLY incapable of making PERSONAL and FINANCIAL decisions, and, if the latter, the kinds of decisions which the respondent can and cannot make. Include the reasons for this opinion:

4. What, in your opinion, is the most appropriate living arrangement for the respondent and, if applicable, describe the most appropriate treatment or habilitation plan. Include reasons for your opinion.

5. Provide a statement describing the certification, license, or other credentials of the physician preparing this report.

(OVER) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

REPORT OF PHYSICIAN

(Rev. 11/01/01) CCP 0211B

___________________________________________
(Print or Type Physician's Name)

Signed: *____________________________________________ Address: ___________________________________________ City/State/Zip: ______________________________________ Telephone: __________________________________________
*See reverse side

___________________________________________
(License No.)

*This report must be signed by a physician. If the description of the respondent's mental, physical, and educational condition, adaptive behavior, or social skills is based on evaluations by other professionals, all professionals preparing evaluations must also sign the report. Evaluations upon which the report is based must have been performed within 3 months of the date of the filing of petition.

Names and signatures of other persons who performed evaluations upon which this report is based:
Name _____________________________________________________________________________________________ Address ___________________________________________________________________________________________ Certification, licenses, or other credentials ______________________________________________________________

______________________________________________________________________________________________________
Signature __________________________________________________________________________________________

Name _____________________________________________________________________________________________ Address ___________________________________________________________________________________________ Certification, licenses, or other credentials ______________________________________________________________

______________________________________________________________________________________________________
Signature __________________________________________________________________________________________

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS