Free Microsoft Word - 538PC.dot - South Carolina


File Size: 330.2 kB
Pages: 2
Date: April 13, 2006
File Format: PDF
State: South Carolina
Category: Court Forms - State
Author: cyon
Word Count: 388 Words, 2,340 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.judicial.state.sc.us/forms/pdf/538PC.pdf

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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.
Has this person ever been rated or found: disabled mentally ill or incompetent chemically dependent 3. 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. 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. 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 Yes Yes No No No No No 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 Yes Yes No No No No No No No Unknown Unknown Unknown Unknown Unknown Unknown Unknown Yes Yes Yes No No No Unknown Unknown Unknown Yes No


2.

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 Yes No

FORM #538PC (2/2004) 62 5-303, 62-5-407

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7.

To your knowledge does this person have: a power of attorney a health care power of attorney or a "living will" Yes Yes Yes No No No Unknown Unknown Unknown

8.

Does the above person have any of the following coverages? health insurance medicare medicaid veteran's health care Yes Yes Yes Yes No No No No Unknown Unknown Unknown Unknown

9.

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 , 20

day of

Date:

Examiner's Signature

Notary Public for South Carolina My Commission Expires:

Examiner's Name

Use this space for explanations or additional comments.

FORM #538PC (2/2004)

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