Form 17.1 - Statement Of Expert Evaluation - Probate Court Of Greene County, Ohio Page 2
Download a blank fillable Form 17.1 - Statement Of Expert Evaluation - Probate Court Of Greene County, Ohio in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 17.1 - Statement Of Expert Evaluation - Probate Court Of Greene County, Ohio with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4CASE NO.
4. Is the individual presently under medication? ☐ Yes ☐ No If yes, what is the medication, dosage, and purpose?
Are there any signs of physical and/or mental impairments caused by the medications themselves?
5. Is the individual mentally impaired? ☐Yes ☐ No If yes, indicate the diagnosis below:
☐ Mental Retardation/Developmental Disabilities:
☐ Profound
☐ Severe
☐ Moderate
☐ Mild
☐ Mental Illness: Type and Severity
☐ Substance Abuse: Description
☐ Dementia: Description
☐ Other: Description
Please provide additional comments and test scores if available. (Continue comments on page 4):
During the examination did you notice an impairment of the individual’s:
6.
☐ Yes
☐ No
☐ Unknown
a) Orientation
☐ Yes
☐ No
☐ Unknown
b) Speech
☐ Yes
☐ No
☐ Unknown
c) Motor Behavior
☐ Yes
☐ No
☐ Unknown
d) Thought Process
☐ Yes
☐ No
☐ Unknown
e) Affect
☐ Yes
☐ No
☐ Unknown
f)
Memory
☐ Yes
☐ No
☐ Unknown
g) Concentration and comprehension
☐ Yes
☐ No
☐ Unknown
h) Judgment
7.
Please describe any impairments identified in question six. (Continue comments on page 4).
FORM 17.1 - STATEMENT OF EXPERT EVALUATION
PAGE 2
5/9/06
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal