Court Investigator'S Report On Proposed Guardianship Page 3

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CASE NO._____________

B. Mental Status Observations: During interview were impairments noted in the

Individual’s:

Yes

Unable to Determine

1. Orientation (Person, Place and Time)

2. Speech

3. Thought Process

4. Affect

5. Memory

6. Concentration & Comprehension

7. Judgment

Explain further if necessary:_______________________________________________________

______________________________________________________________________________.

C. Describe the Physical Condition of Individual

1. Isolation_______________________________________________________________

2. Eating Habits___________________________________________________________

3. Significant Weight Loss or Gain____________________________________________

4. Sleep Habits___________________________________________________________

5. Motor Behavior ________________________________________________________

Explain further if necessary:_________________________________________________

________________________________________________________________________

D. Describe the Environmental or Living Condition of the Individual:

1. Housing & Sanitation___________________________________________________

2. Risk of Accidents_______________________________________________________

3. Physical Barriers________________________________________________________

4. Resource Availability____________________________________________________

Explain further if necessary:_________________________________________________

_______________________________________________________________________.

III. Functional Capacities

Activities and Instrumental Activities of Daily Living

Capable

Incapable

Unable to Determine

1. Eating

2. Dressing

3. Transfer from bed

4. Toileting

5. Bathing

17.8 COURT INVESTIGATOR’S REPORT ON PROPOSED GUARDIANSHIP

Eff. Date October 1, 2007

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