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Rev. 4/25 PHYSICIAN’S REPORT LR29-PR00-714.20; LR29-PR00-714.50 FORM PR00-10 STATE OF INDIANA ) IN THE HAMILTON SUPERIOR COURT ) SS: COUNTY OF HAMILTON ) CAUSE NO. IN THE MATTER OF THE GUARDIANSHIP OF: PHYSICIAN’S REPORT , a physician licensed to practice medicine in all its branches in the State of Indiana, submits the following report on , an alleged incapacitated person, based on an examination of said person on the day of , 20 . 1. Describe the nature and type of the incapacitated person’s disability: 2. Describe the incapacitated person’s mental and physical condition. When it is appropriate, describe the person’s educational condition, adaptive behavior, and social skills: 3. State whether, in your opinion, the incapacitated person is totally or only partially incapable of making personal and financial decisions; if the latter, please state the kinds of decisions which the incapacitated person can and cannot make. Include the reason(s). 4. What, in your opinion, is the most appropriate living arrangement for the incapacitated person? If applicable, describe the most appropriate treatment or rehabilitation plan. Include the reasons for your opinion. 5. Can the incapacitated person appear in court without injury to his/her health? (Note: This is not inquiring as to whether the individual is competent to give testimony or can understand the proceedings.) ---PAGE BREAK--- Rev. 4/25 I affirm under the penalties for perjury that the foregoing representations are true and accurate. Signature: Printed Name: Address: City/State/Zip: Telephone: This report must be signed by a physician. If the description of the incapacitated person’s mental or physical health, or his/her educational condition, adaptive behavior, or social skills is based on evaluations by other professionals, all professionals preparing evaluations must sign the report. Evaluations upon which the report is based must have been performed within three months of the date of the filing of the petition. Names and signatures of other persons who performed an evaluation upon which this report is based: Name: Address: Signature: Name: Address: Signature: Name: Address: Signature: Name: Address: Signature: SIGN SIGN SIGN SIGN SIGN