Indiana Guardianship Form E-13 - Physician'S Report

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Guardianship Form E-13 (2010)
STATE OF INDIANA
)
IN THE ELKHART COUNTY COURT
COUNTY OF ELKHART
)
SUPERIOR COURT #1
)
CAUSE NO. _________________________
IN RE: THE GUARDIANSHIP OF
)
)
PHYSICIAN’S REPORT
________________________________________ )
PROTECTED PERSON
_______________________________________ , a Physician holding an unlimited license to practice
medicine in the State of Indiana, submits the following report on _________________________,
(“Patient”), based upon examination of the Patient.
1.
Set forth the dates of all examinations of the Patient within the last (1) year from the date of this
report.
2.
In your opinion, based upon your examination and observation of the Patient, is the Patient
incapacitated? If so, describe the nature and type of incapacity.
3.
In your opinion, based upon your examination and observation of the Patient, how long has the
Patient been incapacitated?
Describe the Patient’s mental and physical condition; and, if appropriate, describe the Patient’s
4.
educational condition, adaptive behavior and social skills.
1

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