Physicians Report (Adult Ward)

IN THE CIRCUIT COURT OF THE EIGHTH JUDICIAL CIRCUIT, _________________ COUNTY, FLORIDA IN RE: GUARDIANSHIP / GUARDIAN ADVOCACY OF ________________________________, Ward. CASE NO. ________________________ ________________________________________________________________________ PHYSICIAN'S REPORT (adult ward) Reference: Florida Statute 744.3675 1. Physician's Name:_____________________________________________________ 2. Physician's Address ________________________________________________________________________ _________________________________________________________________ 3. Report of Examination of Ward: A. Examination Date_______________________________________________ B. Purpose of Examination: ______Routine checkup ______Treatment for______________________________________________________ _______________________________________________________________________ 4. The ward's mental and physical condition at time of the examination is: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 5. Description of ward's capacity to live independently: _________________________ _______________________________________________________________________ _______________________________________________________________________ 6. The ward (does) (does not) continue to need assistance of a guardian. 7. Is the ward capable of being restored to capacity at this time? (Yes) (No) 8. Signature of Physician _______________________ Report date: ____________20____ American LegalNet, Inc. www.FormsWorkFlow.com